Enrollment Packet 2015-2016 Student Name

Transcripción

1301 west 14th street │ chicago, illinois
60608
p 773.534.7755 │ f 773.534.7757
Enrollment Packet 2015-2016
Student Name:
Date of Birth:
CPS ID#
Please fill out ALL of the forms in this packet AND provide the following documents:
 A signed copy of the acceptance letter
 A copy of the student’s birth certificate
 Certificate of Child Health Examination and Vaccination Record
Completed after September 2014
 Proof of residency (address verification)
Such as a recent utility bill, driver’s license, or state of Illinois ID card
 A copy of the student health insurance coverage
 A copy of your most recent report card
 A copy of the student’s most recent standardized test scores
ISAT and/or EXPLORE
 A copy of the student’s most recent ACCESS scores (if applicable)
 A copy of the student’s IEP (if applicable)
facebook.com/chitechacademy │ twitter.com/chitechacademy │ chitech.org
60608
p 773.534.7755 │ f 773.534.7757
Student and Family Information Form
Student Information
Student’s First Name____________________________ Student’s Last Name_________________________
Student’s Date of Birth:____________________________________________________________________
Social Security Number: ___________________________________________________________________
CPS ID Number: __________________________________________________________________________
Address: ________________________________________________________________________________
City____________________________ State ____________ Zip Code _______________________________
Student Email Address: ____________________________________________________________________
Parent Information
Mother’s First Name: __________________________ Mother’s Last Name: _________________________
Address: ________________________________________________________________________________
Mother’s Email Address ___________________________________________________________________
Phone Number ____________________________ Alternate Phone Number ________________________
Father’s First Name: __________________________ Father’s Last Name: __________________________
Address: ________________________________________________________________________________
Father’s Email Address: ___________________________________________________________________
Phone Number: ___________________________ Alternate Phone Number _________________________
60608
p 773.534.7755 │ f 773.534.7757
Early Dismissal Release Authorization
Student Name: _
Date of Birth: _
CPS ID# _
__________________________________________
The following people have your authorization to release your child from school. Please not that they
will be the only ones who can release your child. A valid ID must be presented at all times to the office
clerk, and they must be 18 years or over.
Name
Relationship
Work Phone_
_Home Phone_
Name
Cell Phone_
Relationship
Work Phone_
_Home Phone_
Name
Cell Phone_
Relationship
Work Phone_
_Home Phone_
Name
Cell Phone_
Relationship
Work Phone_
_Home Phone_
Name
Cell Phone_
Relationship
Work Phone_
_Home Phone_
Cell Phone_
60608
p 773.534.7755 │ f 773.534.7757
Autorizacion para entrega de salida temprana
Nombre de el estudiante:_
Fecha de nacimiento:_
Numero de identificacion de CPS:
Las siguientes personas tienen tu autorizacion para extraer a tu hijo/a de la escuela. Porfavor recuerda
que solamante las personas nombradas en esta forma prodran sacarlos, deberan presentar una
identificacion valida a todo momento a el personal de la oficina y tendran que ser mayores de 18 años.
Nombre_
Relacion/parentesco_
Numero de trabajo
Numero de casa_
Nombre_
Numero de celular_
_Relacion/parentesco_
Numero de trabajo
Numero de casa_
Nombre_
Numero de celular_
Numero de trabajo
Numero de casa_
Nombre_
Numero de celular_
Numero de trabajo
Numero de casa_
Nombre_
Numero de celular_
Numero de trabajo
Numero de casa_
Nombre_
Numero de celular_
Numero de trabajo
Numero de casa_
Numero de celular_
60608
p 773.534.7755 │ f 773.534.7757
Media and Research Release Form
Student’s name: ______________________________________________________________________
Parent’s Name: (Parent/Legal Guardian): __________________________________________________
Student’s Residence Address: (Note: No P.O. Boxes)
Street:
Apt. #:_
City:
Phone: (
County:
State:
Zip:
)
It is possible that your student will be interviewed and/or photographs or videos may be taken of your
student in their activities as a student at ChiTech. We need your permission to use information from an
interview and/or videos and any reproductions thereof in such manner, for such purpose, and in such
publications as ChiTech or its designees may determine.
I hereby release and discharge ChiTech, its Board of Directors or its designee from any and all liability
in connection with such publications and use.
Occasionally your student will be involved in research that will help ChiTech improve its instructional
and support services to our students and parents. Data collected in this research will be used for public
reports. Your student’s name or any other identifying information will not be used in these reports.
ChiTech will give me notification and information about this research whenever it occurs.
I have not received, and do not expect to receive, any financial payment for these uses.
ChiTech may publish the parent and student’s name, address, e-mail, telephone number, and
photograph in a student directory.
As the parent or guardian of the above named student, I consent to the above release.
Parent/Guardian Signature:
_Date:
60608
p 773.534.7755 │ f 773.534.7757
Forma de Liberacion de Medios (de comunicacion) e Investigacion
Nombre: (Padre/Tutor legal)
Nombre Completo de el Estudiante: ______________________________________________________
Numero de Seguro Social:
Direccion de Residencia de el Estudiante: (Nota: No cajas de correo postal)
Calle:
# De Apt:_
Ciudad:
Telefono: (
Condado:
Estado:
CP:
)
Es posible que tu estudiante sea entrevistado y/o fotografias y videos pueden llegar a ser tomados de
ellos en sus actividades como estudiante de ChiTech. Necesitamos tu permiso para utilizar informacion
de alguna entrevista y/o videos o cualquier reporduccion de el mismo y de tal manera, que es para tal
proposito y en dichas publicasiones como los designatarios de ChiTech puedan determinar.
Yo por la presente libero a ChiTech, Consejo de Directores, y sus designatarios de cualquier y toda
responsabilidad en coneccion con tales publicaciones y su uso de estas.
Ocasionalmente el estudiante estara involucrado en investigaciones que ayudaran a ChiTech a
incrementar sus servicios de apoyo y enseñanza para nuestros estudiantes y padres. El nombre de tu
estudiante y cuanquier otra informacion que le identifique no sera utilizada en estos reportes. ChiTech
te dara notificacion e informacion acerca de estas investigaciones cada vez que ocurran.
Yo no he recibido, ni espero recibir ningun pago financiero por estos usos.
ChiTech puede publicar el nombre de el estudiante, direccion, correo electronico, telefono y fotografia
en el directorio estudiantil.
Como padre o tutor de el estudiante nombrado en la parte superior, accedo a la liberacion
mencionada.
Firma de Padre/Tutor Legal:
Fecha:
60608
p 773.534.7755 │ f 773.534.7757
Technology Code of Conduct/Usage
Student Name:_
CPS ID#
Each ChiTech student has the PRIVILEGE to use the hardware and software that has been placed in the computer labs,
classrooms, and issued to students to facilitate personal academic growth.
Each ChiTech student has the RESPONSIBILITY to understand and act in a manner that adheres to the following
technology code of conduct guidelines:








Treat all equipment with care. If you do experience a hardware/software problem, please notify your instructor
immediately. Do not attempt to make any adjustment on your own, unless instructed to do so. Ask for help
before using a piece of hardware or software if you are unfamiliar with its operation.
Hardware and manuals are to remain in the labs or classrooms unless the student has approval from the
instructor to borrow them.
ChiTech students should not install or modify software, unless requested by instructor. Only ChiTech approved
software that is an integral part of a teacher-defined activity will be allowed.
All food, candy, gum or drinks are to be kept out of the computer labs, classrooms, and away from the hardware.
Use of all computing facilities and equipment must be in support of education and consistent with the purposed
of the ChiTech School.
It is unethical and possibly illegal to access or copy files that are private property of another user unless you have
permission from the instructor or the file creator to do so. All ChiTech student a must adhere to the copyright
laws.
It is everyone’s responsibility to see that equipment is not used for illegal or inappropriate purposes or violates
the intended use of the hardware network and/or purpose and goal. Use of internet chat sites and obscene
activities will be defined as a violation of generally accepted social standards for use of a publicly operated
computer network and be subject to disciplinary action including suspension.
ChiTech students must be aware of and adhere to the ChiTech School Student Code of Conduct and all ChiTech
policies and procedures.
I should NOT loan or give my password to anyone. I am solely responsible for any internet access associated with the
use of my password. I understand that my parents and I are solely responsible for any loss/damage of any ChiTech
technology equipment.
Any violation of these guidelines will be considered grounds for disciplinary action, loss of computer lab privileges
and/or access to computers for classroom or home use.
The undersigned understands that the use of this technology is a privilege extended to ChiTech students to enhance
learning and exchange information. I/We understand and agree to abide by this Technology Code of Conduct, and
further understand that ChiTech assumes no responsibility for the student’s communication while using such
technology. Financial restitution may be required for unauthorized use or any damages caused.
Student Signature:
Date:
Date:
60608
p 773.534.7755 │ f 773.534.7757
Codigo de conducta y uso de Tecnologia
Nombre de el estudiante:_
_Numero de identificación de CPS:_
Cada estudiante tiene el PRIVILEGIO de usar el equipo de computadoras y los programas que han sido colocados en los laboratorios de
computacion, salones de clase, y prestados a los estudiantes para facilitar su crecimiento academico personal.
Cada estudiante de ChiTech tiene la RESPONSABILIDAD de enteder y comportarse de manera que se se adhiera a las siguientes normas
de el codigo de conducta de tecnologia:









Tratar todo el equipo con cuidado. Si experimentas algun problema o dificultad con el equipo o su programacion, porfavor avisa a tu
instructor immediatamente. No intentes hacer ni un tipo de ajustes por tu propia cuenta a menos que se el instructor te haya dado
instrucciones de hacerlo. Pide ayuda antes de utilizar alguna pieza de equipo o programacion si no estas familiarizado con su
funcionamiento.
Todo el Equipo, su programacion y manuales deben a toda hora permanecer dentro de el laboratorio o salon de clase, a menos que
el estudiante tenga aprovacion previa de un instructor para tomarlos prestados.
Los estudiantes de ChiTech, no deben instalar o modificar la programacion, a menos que les haya sido requerido por el Instructor.
Todo tipo de comida, dulces, chicles, o bebidas deben ser mantenidas fuera de el laboratorio de computacion, salones de clase y
lejos de todo equipo de computacion.
El uso de las facilidades y equipo de computacion debe ser en apoyo a la educacion y consistente con el proposito de la escuela
ChiTech.
Solamente programacion aprovada por ChiTech y que sea una parte integra para alguna actividad definida por el maestro/a va a ser
permitida.
Es falta de etica & ilegal tomar acceso de o copiar archivos que son propiedad privada de otro usuario a menos que tengas el
permiso o autorizacion de el instructor o el creador de el archivo para hacerlo. Todo estudiante de ChiTech debera adherirse a las
leyes de derechos de reproduccion.
Es la responsabilidad de todos asegurar que el equipo de computacion NO sea utilizado con propositos ilegales o inapropiados los
cuales violan o profanan el objetivo y proposito de uso intencionado de el equipo y red. El uso de paginas de charla de internet a el
igual que paginas de actividad obcena, seran definidas como una violacion de estadares generalmente aceptados socialmente para
el uso de red en una computadora, la cual su funcion es de uso publico, y seran sujetos a accion disciplinaria, incluyendo suspencion.
Los estudiantes de CAAT deberan estar concientes de adherirse a codigo de conducta escolar de el estudiante a el igual que todas la
politicas, procedimientos y normas de CAAT
Yo (el estudiante) NO voy a prestar o dar mi contraseña a nadie. Soy unico responsable por cualquier acceso a el internet asociado con mi
contraseña.
Yo (el estudiante) entiendo que mis padres y yo somos los unicos responsables por cualquier daño o perdida causada por mi, a cualquier
equipo de tecnologia de ChiTech.
Cualquier violacion de estas normas seran consideradas como terreno para accion disciplinaria, incluida la perdida de privilegios de el
alboratorio de computacion y/o acceso a computadoras para uso de salon de clases o de el hogar.
Las firmas abajo indicant que entendemos que el uso de esta tecnologia es un privilegio otorgado a los estudiantes de ChiTech para
mejorar su aprendizaje e intercambio de informacion. Yo/nosotros entendemos y estamos de acuerdo en acatarnos a el codigo de
conducta de tecnologia y mas aun entendemos que ChiTech no assume ninguna responsabilidad por el uso de comunicacion de el
estudiante mientras en uso de tal tecnologia, restitucion financiera puede llegar a ser requerida por el uso no autorizado o daños
causados por esta accion.
Firma de el estudiante:
Fecha:
Firma de el padre/tutor legal:
Fecha :
60608
p 773.534.7755 │ f 773.534.7757
Race and Ethnicity Survey
Student Name:_
Date of Birth:_
CPS ID#_
INSTRUCTIONS: Please answer the questions below. Both questions must be answered. Part A asks
about the student’s ethnicity and Part B asks about the student’s race. If you decline to respond to
either question, the school district is required to provide the missing information by observer
identification.
Part A. Is this student Hispanic/Latino? ( A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race.) Choose only one.
 No, not Hispanic/Latino
 Yes, Hispanic/Latino
The question above is about ethnicity, not race. No matter which answer you selected, continue and
respond to the question below by marking one or more boxes.
Part B. What is the student’s race? Choose one or more.
 American Indian or Alaska Native (A person having origins in any of the original peoples of
North and South American, including Central American, and who maintains tribal affiliation or
community attachment.)
 Asian ( A person having origins in any of the original peoples of the Far East, Southeast Aisa,
or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)
 Black or African American (A person having origins in any of the black racial groups of
Africa.)
 Native Hawaiian or Other Pacific Islander (A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
 White ( A person having origins in any of the original peoples of Europe, the Middle East, or
North African.)
60608
p 773.534.7755 │ f 773.534.7757
Encuesta de Raza y de Origen Étnico
Nombre de Estudiante:
Fecha de Nacimiento:_
CPS ID#_
INSTRUCCIONES: Conteste por favor las preguntas siguientes. Ambas preguntas tienen que ser
contestadas. Parte A le pregunta sobre el origen étnico del/de la estudiante y Parte B sobre la raza
del/de la estudiante. Si se niega a responder a una o a las dos preguntas, se obliga que el distrito
escolar proporcione la información que falta por identificación observada.
Parte A. ¿Es hispano/latino el/la estudiante? ( Una persona de cultura y origen cubano, mexicano,
puertorriqueño, sudamericano, centroamericano, o cualquier origen latino-americano, sin importar la
raza.) Escoja sólo una.
 No, no es hispano/latino
 Sí, es hispano/latino
La pregunta arriba se trata del origen étnico, no de raza. A pesar de la respuesta que seleccionó usted,
continúe y responda a la pregunta abajo por marcar una o más de una de los cuadros.
Parte B. ¿Qué es la raza del/de la estudiante? Escoja una o más.
 Amerindio o Indígena de Alaska (Una persona con orígenes en cualesquiera de los pueblos de
América del Norte y de Latinoamérica, y quien mantiene afiliación tribal o relación comunitaria oficial.)
 Asiático (Una persona con orígenes en cualesquiera de los pueblos originales del Extremo Oriente, el
Sudeste Asiático, o el subcontinente indio, incluso por ejemplo, Camboya, China, la India, Japón, Corea,
Malasia, Pakistán, las Islas Filipinas, Tailandia, y Vietnam.)
 Negro o Afroamericano (Una persona con orígenes en cualesquiera de los grupos raciales negros de
África. Pueden ser los afroamericanos o los inmigrantes procedentes de ciertas zonas del Caribe con
mayoría negra.)
 Polinesios o Isleños del Pacífico (Una persona con orígenes en cualesquiera de los pueblos originales
de Hawái, Guam, Samoa o cualquier otra isla del Océano Pacífico.
 Blanco (Una persona con orígenes en cualesquiera de los pueblos originales de Europa, Oriente
Medio, el norte de África.)
60608
p 773.534.7755 │ f 773.534.7757
Request for Emergency Information
Student’s name: (first)
(middle)
(last)
Confidential Information Box 1
Complete this box only if (1) It reflects your child’s current living situation or (2) your living situation if you are a you th not
living with a parent or guardian. (Your answer will help school staff with school enrollment and may enable the student
to receive additional services.) Check one box if you are living:
 In a shelter
 With relatives or others due to lack of housing
 In an abandoned apartment/building
 In a motel/hotel, campground, or other similar situation due to the lack of alternative, adequate housing
 Temporarily housed in a shelter awaiting a DCFS permanent foster care placement
Student’s Residence Address: (Note: No P.O. Boxes)
Apt. #
Parent/Guardian Emergency Information
State
Zip
Name_
Name_
Phone (
City
Parent/Guardian Emergency Information
Phone (
_)
Address_
Address_
Name of Employer
Name of Employer
Work Phone (_
_)
Work Phone (_
)
)
Address of Employer_
Address of Employer_
Confidential Information Box 2
Is there a current Order of Protection or No Contact order which concerns the student:  Yes
 No
Please give the name of a relative or neighbor who could be notified in case of illness or accident:
_
Name
Address
Name
Address
(
(
)_
Telephone
Relationship
)_
Telephone
Relationship
If we cannot reach you and feel that your family doctor is needed, please supply this information:
Family Doctor
Address
I authorize you to call my doctor, if necessary
(
)_
Telephone
60608
p 773.534.7755 │ f 773.534.7757
Solicitud de Información de Emergencia
Nombre del Estudiante: (nombre)
(inicial)
(apellido)
Encasillado 1 Información Confidencial
Complete esta información sólo (1) si refleja las condiciones de vida actuales de su hijo/a o (2) sus propias condiciones de
vida, si es usted un/a joven que no está acompañado/a por uno de sus padres. (Su respuesta/s ayudará/n al personal escolar
con la matricula y puede que ayude a queel o la estudiante pueda recibir servicios adicionales.) Marque una casilla o
cuadrito si vive en:
 Un refugio
 Un tren o estación de autobuses, parquet o automóvil
 Un apratamento u edificio abandonado
 Casa de familiars u otras personas por falta de un lugar donde vivir
 Un motel/hotel, lugar para acampar o en
situaciones o lugares similares debidoo a la ausencia de otro lugar alterno adecuado para vivir
 Algun hogar, colocado temporalmente, en espera de ser asignado por DCFS a una familia que lo cuide
Dirección o Domicilio del Estudiante:
Información de Emergencia del Padre, Madre, encargado o
Tutor Legal
Información de Emergencia del Padre, Madre, encargado o
Tutor Legal
Nombre
Nombre
Teléfono (_
)
Teléfono (_
)
Dirección
Dirección
Nombre del Empleador
Nombre del Empleador
Teléfono del Empleador (
)
Teléfono del Empleador (
Dirección del Empleador
)
Dirección del Empleador_
Encasillado 1 Información Confidencial
¿Existe una Orden de Protección o de Prohibición de Comunicatión o de Contacto que concieme a este estudiante?:
 Si
 No
Por favor, provéanos con el nombre de un panente, amigo, o vecino que pueda ser notificado en caso de que su hijo/a se
enferme o tenga un accidente:
_
Nombre
(
Dirección
(
Nombre
Dirección
)_
Teléfono
Relación
)_
Teléfono
Relación
En caso de no encontrario a usted y fuese necesario que su medico familiar esté presente, por favor, facilitenos la información siguiente:
Nombre del Doctor de la Familia
Dirección
Autonzo llamar mi médico familiar si fuese necesario.
Firma
(
)_
Teléfono
STATE OF ILLINOIS DEPARTMENT OF HUMAN
SERVICES CERTIFICATE OF CHILD HEALTH
EXAMINATION
Please Print
Student’s Name
Birth Date
Last
Address
First
Street
Middle
City
Sex
School
Grade Level /ID#
Month/Day/ Year
Parent/
Guardian
ZIP code
Telephone #
Home
Work
IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if
the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining
the medical reason for the contraindication.
VACCINE/DOSE
Diphtheria, Tetanus and Pertussis
(DTP or DTaP)
1
DA
MO
YR
2
DA
MO
YR
MO
3
DA
YR
MO
4
DA
YR
MO
5
DA
YR
MO
6
DA
YR
Diphtheria and Tetanus (Pediatric DT or Td)
Inactivated Polio (IPV)
Oral Polio (OPV)
Haemophilus influenzae type b (Hib)
Hepatitis B (HB)
Comments
Varicella (Chickenpox)
Combined Measles, Mumps and Rubella
(MMR)
Measles (Rubeola)
Rubella (3-day measles)
Mumps
Pneumococcal (not required for school entry)
PCV7 PPV23
PCV7 PPV23
PCV7 PPV23
PCV7 PPV23
PCV7 PPV23
PCV7 PPV23
Check specific type (PCV7, PPV23)
Other (Specify hepatitis A, meningococcal, etc.)
Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below.
Signature
Title
Date
Title
Date
Title
Date
Signature
(If adding dates to the above immunization history section, put your initials by date(s) and sign here.)
Signature
(If adding dates to the above immunization history section, put your initials by date(s) and sign here.)
ALTERNATIVE PROOF OF IMMUNITY
1.
Clinical diagnosis is acceptable if verified by physician.
*(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.)
*MEASLES (Rubeola) MO DA YR MUMPS MO DA YR
VARICELLA MO DA YR
Physician’s Signature
2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.
Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease.
Date of Disease
3.
Signature
Title
 Measles
Laboratory confirmation (check one)
Lab Results
Date
 Mumps
MO
DA
 Rubella
Date
 Hepatitis B
 Varicella
(Attach copy of lab report, if available.)
YR
VISION AND HEARING SCREENING DATA
Pre-school – annually beginning at age 3; School age – during school year at required grade levels
Date
Age/Grade
R
L
R
L
R
L
R
L
R
L
R
L
R
L
Vision
Hearing
Printed by Authority of the State of Illinois
(Complete Both Sides)
IL444-4737 (R-01-05)
R
L
R
L
R
L
Code:
P = Pass
F = Fail
U = Unable to
test
R = Referred
G/C = Glasses/
Contacts
Last
First
HEALTH HISTORY
ALLERGIES
Sex
Birth Date
Student’s Name
Middle
School
Grade Level/ ID #
Month/Day/ Year
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
MEDICATION
(Food, drug, insect, other)
Yes
Diagnosis of asthma?
Child wakes during the night coughing Yes
No
No
Birth defects?
Yes
No
Developmental delay?
Blood disorders? Hemophilia,
Sickle Cell, Other? Explain.
Diabetes?
Yes
No
Yes
No
Yes
No
Surgery? (List all.)
When? What for?
Serious injury or illness?
Head injury/Concussion/Passed out?
Yes
No
TB skin test positive (past/present)?
Seizures? What are they like?
Yes
No
Heart problem/Shortness of breath?
Yes
No
No
Heart murmur/High blood pressure?
Yes
Indicate Severity
(List all prescribed or taken on a regular basis.)
Dizziness or chest pain with
Yes
No
exercise?
Eye/Vision problems?
Glasses  Contacts  Last exam by eye doctor
Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Ear/Hearing problems?
Yes
No
Bone/Joint problem/injury/scoliosis?
Yes
No
Loss of function of one of paired
organs? (eye/ear/kidney/testicle)
Yes
No
Hospitalizations?
When? What for?
Yes
No
Yes
No
Yes
No
Yes*
No
TB disease (past or present)?
Yes*
No
Tobacco use (type, frequency)?
Yes
No
Alcohol/Drug use?
Yes
No
Family history of sudden death
before age 50? (Cause?)
Yes
No
Dental
Braces
Other concerns?
Bridge
*If yes, refer to local health
department.
Plate Other
Information may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
Signature
Entire section below to be completed by MD/DO/APN/PA
PHYSICAL EXAMINATION REQUIREMENTS
(*INDICATES
Date
TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES)
HEIGHT
WEIGHT
BMI
B/P
DIABETES SCREENING BMI>85% age/sex Yes  No  And any two of the following: Family History Yes  No  Ethnic Minority Yes  No 
Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes  No 
At Risk
Yes  No 
LEAD RISK QUESTIONNAIRE* Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten.
Blood Test Indicated? Yes  No  Blood Test Date
Blood Test Result
(Blood test required in Chicago and other high risk zip codes.)
TB SKIN TEST Recommended only for children in high-risk groups including children who are immunosuppressed due to HIV infection or other conditions, recent immigrants from high
prevalence countries, or those exposed to adults in high-risk categories. See CDC guidelines.
Date Read
/ /
Result
mm
LAB TESTS *INDICATES TESTING
MANDATED FOR STATE LICENSED CHILD
CARE FACILITIES
Date
Results
Date
Hemoglobin * or Hematocrit *
Sickle Cell * (as indicated)
Urinalysis
SYSTEM REVIEW Normal
Other
Comments/Follow-up/Needs
Normal
Skin
Endocrine
Ears
Gastrointestinal
Eyes
Normal
Yes No Objective screening Yes No Result
Amblyopia Yes No Referred to Opthalmologist/Optometrist Yes No
Results
Comments/Follow-up/Needs
_ Genito-Urinary
LMP
Neurological
Nose
Musculoskeletal
Throat
Spinal examination
Mouth/Dental
Nutritional status
Cardiovascular/HTN
Mental Health
Respiratory
NEEDS/MODIFICATIONS required in the school setting
DIETARY Needs/Restrictions
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup
MENTAL HEALTH/OTHER
Is there anything else the school should know about this student?
If you would like to discuss this student’s health with school or school health personnel, check title:
 Nurse
 Teacher
 Counselor  Principal
EMERGENCY ACTION needed while at school due to child’s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)?
Yes  No  If ye s, please describe.
On the basis of the examination on this day, I approve this child’s participation in
PHYSICAL EDUCATION
Yes 
No 
Modified 
(If No or Modified,please attach explanation.)
INTERSCHOLASTIC SPORTS (for one year)
Yes 
Physician/Advanced Practice Nurse/Physician Assistant performing examination
Print Name
Address
Signature
Date
Phone
(Complete both sides)
No 
Limited 

Enrollment Packet 2015-2016 Student Name

Transcripción

Documentos relacionados