Diocese of Harrisburg Permanent Elementary School Record. Pupil Sex (last) (First) (Middle) Change of Address

Transcription

1 (596) iocese of Harrisburg Permanent Elementary School Record z )> 5: m SCHOOL CITY Pupil Sex (last) (First) (Middle) Address Resident Public School istrict Change of Address Telephone Change of Telephone Place of Birth ate of Birth----- Citizenship SS# Registered Parish Location Admitted from ate Grade (School) (Address!) Parish City!Town & State ate Baptism First Penance First Eucharist Confirmation - VerifiedO Father Mother Guardian Name Occupation Religion Education (Circle) Elem. Sec. Coli. Adv. (First and Maiden) Elem. Sec. Coli. Adv. Elem. Sec. Coli. Adv. Siblings Relationship of guardian to child Home Situation: One parent ( Parents Separated or ivorced ( ) Restructured - Stepfather/mother ( Father remarried ( ) Mother Remarried ( ) Child resides with Parental Rights (in case of separation or divorce) :(_; Att_a_c h_c_;op~y-of_c_o u_rt_o_rd_e_.:_r) Language (other than English) spoken at home WITHRAWAL RECOR RE-ENTRY RECOR ate To Cause* ate From Grade Reason wrthdrawal Causes: 1. Illness; 2. eath; 3. Left City; 4. Graduation; 5. Financial ifficulties; 6. Parents' Wish; 7. School Request; 8. Institutionalized; 9. Other Reasons

2 PUPIL HEALTH HISTORY (To be completed by parent or guardian) The information on this fonn will help the School Nurse maintain an accurate health record of your child and will enable School Personnel to assist your child and to receive maximum benefrts from his/her educational experience. SCHOOL ~ ATE GRAE STUENTNAME ~-=~ ~~~ (LAST) (FIRST) (MILE} ATE OF BIRTH HOME PHONE HOME ARESS FATHER'S NAME :-----:: ==-=-= : (LAST) (FIRST) {MILE) MOTHER'S NAME ::-::-=::= ==-=:= (LAST) (FIRST) (MILE) PERSON WITH WHOM PUPIL RESIES RE~IONSHIPTOPUPIL ~~ IMMUNIZATIONS (PLEASE PROVIE IMMUNIZATION RECORS} **STUENT MAY NOT START SCHOOL WITHOUT IMMUNIZATION AN/OR EXEMPTION INFORMATION. - IMMUNIZATIONS ATTACHE CHECKE BY~---- ATE ----'----- RECOR OF ILLNESS. HAS YOUR CHIL HA ANY OF THE FOLLOWING? GIVE ETAILS. ALLERGIES FOO RUG BEE/INSECT SEASONAUENVIRONMENTAL RECURRING ILLNESS OPERATIONS ~--~ ~--~ EMOTIONALPROBLEMS. ~ SERIOUSACCIENTS ~ ORTHOPEIC CONITIONS CHECK IF YOUR CHIL HAS HA ANY OF THE FOLLOWING (NOTE COMPLICATIONS): ANEMIA APPENICITIS ARTHRITIS ASTHMA CHICKEN POX IABETES HEART ISEASE MEASLES (REG) MEASLES (GERMAN) MUMPS RHEUMATIC FEVER SCARLET FEVER SEIZURES T.B. (SELF). WHOOPING COUGH (PERTUSSIS) OTHER- OVER

3 OES YOUR CHIL HAVE ANY HEARING PROBLEMS? ARE THERE ANY OTHER HEALTH PROBLEMS (PHYSICAL OR EMOTIONAL) WHICH YOUR CHIL'S PHYSICIAN OR YOU FEEL SHOUL BE KNOWN TO SCHOOL AUTHORITIES? NAME OF CHILO'S PHYSICIAN NAME OF CHIL'S ENTIST , YOUR CHIL PRESENTLY UNER MEICAL TREATMENT? (SPECIP ATE OF LAST PHYSICAL EXAM ATE OF LAST ENTAL EXAM---- NAME OF PREVIOUS SCHOOL ATTENE ARESS PHONE NUMBER HAS THE STUENT PREVIOUSLY ATTENE SCHOOL IN CAMP HILL SCHOOL ISTRICT? YES NO PLEASE COMPLETE AN RETURN TO THE SCHOOL NURSE Revised April 2006

4 H (Rev 5/02) COMMONWEALTH OF PENNSYLVANIA EPARTMENT OF HEALTH PRIVATE PHYSICIAN'S REPORT OF PHYSICAL EXAMINATION OF A PUPIL OF SCHOOL AGE ATE 20. NAMEOFSCHOOL ~----~ GRAE HOMEROOM NAME OF CHIL Last First Middle ARESS ATE OF BIRTH SEX O M F No. and Street City or Post Office Borough or Township County State Zip Code VACCINE iphtheria and Tetanus (Circle): TaP, TP, T, T Polio (Circle): OPV, IPV Measles, Mumps, Rubella Hepatitis B HIB Varicella Other: MEICAL HISTORY IMMUNIZATIONS AN TESTS Enter Month, ay, and Year each immunization was given OSES 3 I I ( 3 I BOOSTERS & ATES 4 5 I 4 5 I 3 3 I Varicella isease or Lab Evidence ate: 0 MEICAL EXEMPTION The physical condition of the above named child is such that immunization would endanger life or health RELIGIOUS EXEMPTION (Includes a strong moral or ethical conviction similar to a religious belief and requires a written statement from the parent/guardian) If Applicable: Tuberculin Tests ate Applied Arm evice Antigen Manufacturer Signature ate Read Results jmm} Signature Follow-Up of significant tuberculin tests: Parent/Guardian notified of significant findings on Result of iagnostic Studies: ,------:--=---= Preventive Anti-Tuberculosis- Chemotherapy ordered. 0 0 No Yes ate

5 Yes Allergies... Asthma. Cardiac Chemical ependency.~. rugs.. Alcohol.,,,.,;,,;_;:. ; : iabetes Mellitus. 0 Gastrointestinal isorder. Hearing isorder.. Hyp"ertension... Neuromuscular isorder Orthopedic Condition. Re~piratory Illness, Seizure-isorder. ~ Skin isorder. Vision isorder. :. : Other (Specify). Significaht Medical Conditions (J) If Yes, Explain 'NO -~ 0 Are there any special medical problems o~ thr6nic diseages' which require restriction of activity, medication or which mi9,n, l:ll~~9this/p~_( - education? If so, specify-- -~-- _ ~ ~ - --,---,- -' ,.-:-: ~-,---:.,.-"---'----- Report of Phys,ical Examination (,/)... Normal Abnormal Not Examined comments -- Height (inches) Werght(pounds) BMI Pulse ( ) < '. Blood Pressure. Hair/Scalp Skin E-yesNision Ears/Hearing Nose ana lhroat ;. ~ ::, J. ;,.;;. Teeth and Gingiva Lymph Glands. Heart:-Murmur, etc..-.' ~. : ' Lung - Adventitious Finding. Abdomen Genitourinary - ' Neuromuscular System. '. EXtremities Spine (Presence ofscoliosi~) " :. ;-. ate of Examination Signature of Examiner PRINT Name of Examiner Address Telephone Number

6 H COMMONWEALTH OF PENNSYLVANIA EPARTMENT OF HEALTH PRIVATE ENTIST REPORT OF ENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE NAME OF SCHOOL ATE 20 NAME OF CHIL AGE SEX GRAE SECTION/ROOM ARESS Last First Middle M F No. and Street City or Post Office Borough or Township County State Zip REPORT OF EXAMINATION TOOTH CHART RIGHT LEFT UPPER LOWER UPPER A B c E F G H I J T s R Q p 0 N M L K Upper 1 Lower Upper LOWER Lower Is The Child Under Treatment Yes No Treatment Completed Yes No ate of ental Examination Signature of ental Examiner Print Name of ental Examiner Address

7 Side "A" Form E-8 (June 1979) REQUEST FOR TRANSCRIPT OF STUENT RECOR has been admitted Student's Name to the Grade of School Address City State Zip Please forward: Health and ental Records _ Personal Health History _ Transcript of Records Principal Side "B" PARENTAL PERMISSION FOR RELEASE OF STUENT RECOR I herewith give my permission for the release of the information requested on Side "A" for my (son/daughter) Student's Name Grade ate: Signature: Parent of Guardian