Student Handbook Certification. I understand the rights and responsibilities pertaining to students and agree to support and abide by (and agree to have my student support and abide by) the rules, guidelines, procedures and policies of the School District as reflected in the Student Handbook. I acknowledge that the Student Handbook is available online at xxxx://xxx.xxx.xxx and can also be obtained at my student’s school office. Parent/Guardian Initials Student Initials VI. Signature(s) Parent/Guardian Signature: _ _ Date: / / _ Student Printed Name Student Signature: _ _ _ _ Date: / / _ [ ]Student is 18 or older Revised 2007 DENTIST’S REPORT The following services have been performed: (please check) radiographs oral prophylaxis fluoride treatment restorations The following statements are applicable: (please check) all necessary services have been performed. no restorative services are required at this time. further treatment is indicated. future appointments have been arranged. Comments: Date: Signature of dentist Child’s Name DOB • PHYSICIAN’S REPORT IMMUNIZATIONS Physical Assessment Check one: Entirely within normal limits Abnormalities as follows: Asthma ADD/ADHD Behavior concerns Bone/muscle/joint problems Bowel/bladder problems Cystic fibrosis Diabetes Developmental delays Ear problem/hearing difficulty Hemophilia Seizure disorder Sickle cell anemia Skin conditions Speech problems other Is there any reason why the student cannot carryout a full program of school work: Yes No Signature of Health Care Provider Address: Phone #: Date: Date Date Date Date Date DtaP, DPT, DT Polio MMR Hepatitis B
Student Handbook Certification. I understand the rights and responsibilities pertaining to students and agree to support and abide by (and agree to have my student support and abide by) the rules, guidelines, procedures and policies of the School District as reflected in the Student Handbook. I acknowledge that the Student Handbook is available online at xxxx://xxx.xxx.xxx and can also be obtained at my student’s school office. Parent/Guardian Initials Student Initials VI. Signature(s) Parent/Guardian Signature: Date: / / Student Signature: Date: / / [ ]Student is 18 or older Child’s Name PHYSICIAN’S REPORT DOB Physical Assessment Check one: Entirely within normal limits Abnormalities as follows: Asthma ADD/ADHD Behavior concerns Bone/muscle/joint problems Bowel/bladder problems Cystic fibrosis Diabetes Developmental delays Ear problem/hearing difficulty Hemophilia Seizure disorder Sickle cell anemia Skin conditions Speech problems other Is there any reason why the student cannot carryout a full program of school work: Yes No Signature of Health Care Provider Address: Phone #: _ Date: D ENTIST’S REPORT The following services have been performed: (please check) radiographs oral prophylaxis fluoride treatment restorations The following statements are applicable: (please check) all necessary services have been performed. no restorative services are required at this time. further treatment is indicated. future appointments have been arranged. Comments: Date: Signature of dentist Hepatitis B Varicella Hearing: Right Left Vision: Distance acuity Right 20/ Left 20/ Lead Screening Results ALLERGIES: please list (medications, insect stings, food, etc.) Current medications: Any special diet or treatment? Polio MMR DtaP, DPT, DT IMMUNIZATIONS Date Date Date Date Date SCHOOL HEALTH EXAMINATION RECORD SCHOOL GRADE CHILD’S NAME BIRTH DATE LAST FIRST MIDDLE HOME ADDRESS RESIDENCE PHONE PARENT/GUARDIAN’S NAME PARENT/GUARDIAN’S NAME Who does the child live with?
