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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: Please submit on or before 1st day of school.
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

Source: http://sbcs.edu.gu/wp-content/uploads/2011/07/medical-clearance-form.pdf

Read all of this leaflet carefully because

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

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