Microsoft word - enrollment agreement and medical clearance forms sy2011-2012.doc
SANTA BARBARA CATHOLIC SCHOOL
274 W Santa Barbara Ave Ste A, Dededo, Guam 96929-5378 TEL 632-5578 FAX 632-1414 EMAIL info@santabarbaraschool.org WEBSITE http://www.santabarbaraschool.org MEDICAL CLEARANCE FORM FOR SCHOOL ADMISSION Note: Pleasesubmitonorbefore1stdayofschool. STUDENT NAME DATE OF BIRTH ETHNIC GROUP GRADE ENTERING (Please check one) SCHOOL YEAR HOME ADDRESS HOME PHONE MOBILE PHONE FATHER'S NAME MOTHER'S NAME PART 1: PHYSICAL EXAMINATION BLOOD PRESSURE VISION: RT HEARING: RT CHECK EACH LINE Abnormal Not Examined Describe suspicious or abnormal findings General Appearance Skin, Hair, Nails Eyes: External (pupils-cornea) optic fundus Muscle balance Ears: External auditory acuity Tympanic membrane Tympanogram Pure Tone Nose, Mouth Pharynx, Larynx Teeth, Gums Neck, Lymph Nodes Cardiovascular Respiratory Gastrointestinal Genito-Urinary Musculo-Skeletal Scoliosis Screening PART 2: IMMUNIZATION RECORD TOPV, IPV, TOPV, IPV, TOPV, IPV, TOPV, IPV, Td (10 YR) / Tdap Please check one: Perfectly Healthy Specific Problem(s) Noted Handicapped This child is physically fit to participate in physical education and/or athletic events and related activities. Name of Physician (PRINT) Signature SANTA BARBARA CATHOLIC SCHOOL
274 W Santa Barbara Ave Ste A, Dededo, Guam 96929-5378 TEL 632-5578 FAX 632-1414 EMAIL info@santabarbaraschool.org WEBSITE http://www.santabarbaraschool.org MEDICAL INFORMATION TELEPHONE #(S) MOBILE PHONE IS YOUR CHILD ALLERGIC TO ANY MEDICATION? IF YES, WHAT MEDICATION(S)? OTHER ALLERGIES? IS THERE ANY PARTICULAR MEDICAL PROBLEM THAT THE SCHOOL NEEDS TO BE AWARE OF? IF YES, PLEASE EXPLAIN THE MEDICAL PROBLEM BELOW: DO YOU GIVE PERMISSION FOR YOUR CHILD TO BE GIVEN MEDICINE FOR THE FOLLOWING ITEMS BELOW: CHECK ONE PARENT / GUARDIAN PROTOCOL MEDICINE TO BE ADMINISTERED SIGNATURE COUGH or SORE THROAT Cough Drops / Lozenges Ibuprofen (Advil), Acetaminophen MENSTRUAL CRAMPS (Tylenol) EAR ACHE, TOOTACHE, FEVER, HEADACHE Acetaminophen (Tylenol) Peroxide or Betadine (Iodine) / WOUND CARE Over the Counter Ointment IF NO, PLEASE GIVE THE TYPE OF ASPIRIN OR OTHER MEDICATION THAT IS GIVEN TO YOUR CHILD: PROTOCOL MEDICINE TO BE ADMINISTERED COUGH OR SORE THROAT MENSTRUAL CRAMPS EAR ACHE, TOOTACHE, FEVER, HEADACHE WOUND CARE MEDICAL COMMENTS: SIGNATURE OF PARENT OR GUARDIAN
Medical Oxygen - Patient Information Leaflet Read all of this leaflet carefully because it contains important information for you. Keep this leaflet, you may need to read it again. Ask your pharmacist or doctor if you need more information. In this Leaflet Page 1 1. What is Medical Oxygen and what it is used for 4. Possible side effects 5. How to store Medical Oxygen 6. Further i
SANTA BARBARA CATHOLIC SCHOOL
SANTA BARBARA CATHOLIC SCHOOL