Fall Registration Checklist
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- Emory McDaniel
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1 Fall Registration Checklist Please use the following form to check off necessary paperwork needed to get ready for the school year 1. Please complete the following paperwork and items Medical Emergency Form Administration of Medication $200.00/per year Activity Fee Medical Emergency Form School Supply List and Emergency Packet $25.00/Music Fee - applies only to full time students $50.00/Art Expressions Fee 2. Bring all completed paperwork and required materials/fees to registration between June 1-11 th, from 8:45 a.m. - 3:00 p.m.. Thank you for your help in ensuring a seamless start to our new school year. We look forward to working with you. Sincerely, CLU Staff
2 Personal School Supply and Emergency Packet List Each parent is required to drop off at time of registration: Supplies 1-pack lined poster boards 1-box dry eraser markers 1 reams of college ruled paper 1 reams of wide ruled paper 2-3 inch notebooks 1 pack of ball point pens 2 boxes of Kleenex 1 bottle of anti-bacterial gel 1 box of colored pencils 1 box of colored sharpies 4 pack of Lysol or Clorox wipes 1 pack colored or manila folders 4 pack of Sticky or Post-it Note pads 12 packages paper plates 1 package plastic utensils (combo pack) 1-package 100 count cups (5oz) 1-4 pack paper towels 1 box scrub pads 1 box gallon heavy duty trash bags OPTIONAL: 1 box Band-Aids 1 case of Half pint water An Emergency packet for your child MUST be held at the Center for Learning Unlimited in case of an emergency/natural disaster. Each student s packet MUST be supplied by his/her parent or guardian. Update Contents of Emergency Kit The emergency kits will be available during registration for replenishment. Replace perishables Update prescription medications (only pharmacy approved containers will be accepted). Old medications will be available for pick-up.
3 Administration of Medication Authorization Form TO BE COMPLETED IN FULL BY PHYSICIAN AND PARENT BEFORE ANY MEDICATION CAN BE ADMINISTRERED AT SCHOOL. To the Physician Please complete and sign this form if medication prescribed for a school age child must be given during school hours. It is a request and a guide to authorize school personnel to administer medications. Please list any additional medications including prescription and /or over the counter products to be administered during school hours. Include those required for allergic reactions or other special Child s Prescriptive Medication Physician Name (Print) Phone Physician Signature Date To the Parent/Guardian Over-the-Counter (OTC) Medication - To be completed by Parent/Guardian. If unsure of dosage and frequency, please note, as directed on box. Tylenol: Ibuprofen: Cough Suppressant: Sudafed: Benadryl: Claritin: If you wish the school staff to assist your child in taking any prescribed medication or over the counter products, please complete this form and return. I give permission to Center for Learning Unlimited to dispense the listed over-the-counter medication or any prescribed medication as directed above and in accordance with school policy. I understand that an administration or designees will administer medication. I DO NOT give Center for Learning Unlimited permission to dispense medication to my child. Parent/Guardian Signature Date
4 Medical Emergency Form Student Information Male Female Student Name Student Address Last First Middle Grade DOB Street City State Zip Parent/Guardian Information (1) Parent/Guardian Information (2) Dr. Mr. Mrs. Ms. Dr. Mr. Mrs. Ms. Home Phone Cell Phone Home Phone Cell Phone Business Phone Fax Business Phone Fax Pager Pager Name to Call in Case of Emergency (other than parents) Relationship to Student Home Phone Business Phone Cell Phone Insurance Information (Failure to complete could result in a delay in care) Is the Student covered by a Hospitalization/Medical Care Policy? Yes No Insure Company Name Policy Group # Name of Policy Holder SSN of Policy Holder Address of Policy Holder Does the insurance company require pre-authorization? Yes No If yes, Pre-authorization Phone Insurance Company Phone Doctor Name Doctor Phone Allergies (including medicines, foods, bites and stings) None Allergy - List Below Allergic Reaction/Symptoms Medication to Counter Reaction
5 Medical Emergency Form Cont d Hospitalizations/Emergencies (Please list any hospital or emergency department visits in the last 2 years) Dates for Hospital/Emergency Visit Length of Stay Swimming Ability (Please check one) Lifesaving Certification Strong Swimmer Weak Swimmer Non-Swimmer Participant History: Past and Present Medical Problems (To be completed by applicant. Fill in EVERY blank. Use additional pages if necessary) Conditions and Symptoms: Do you have, or have you had, any of the following conditions or symptoms? Please check Yes or No Y N Y N Y N High Blood Pressure Frostbite Ankle Problems Heart Disease Circulation probe Leg Problems Heart Murmur Bedwetting Foot Problem Irregular Heartbeat Headaches Currently Pregnant Family hx of heart attack Neurological impairment Special Diet Tuberculosis Stomach ulcers Learning Disability Recent exposure to active TB Intestinal Problems Medical equipment Positive TB test Heatstroke Weight loss (unexplained) Active Hepatitis Bladder Infections Hx of Hepatitis Difficulty Urinating Seizure Disorder Kidney Problems Chest Pain Seizure within past year Thyroid Problems Heart Palpitations Bleeding Disorder Endocrine Problems Unexplained sweating Blood disorder/anemia/sickle cell trait Hearing Impairment Frequent Shortness of breath Chronic cough Vision Impairment Frequent Dizziness Recurrent lung infections Motion sickness Frequent fainting Asthma Sleep walking Heartburn Diabetes Broken bones Muscle Cramps Hypoglycemia Neck Problems Intolerance to warm temps Anorexia Nervosa Arm Problem Intolerance to cold temps Bulimia Shoulder Problem PMS or menstrual cramps Cancer Knee Problem Other Skin Problems
6 Medical Emergency Form Cont d If you have answered yes to any of the Medical Problems please explain below. Include the following: What specific symptoms are occurring How often symptom/condition occurs How long symptom/condition lasts Date of last occurrence How symptom/condition restricts the student activity in any way, including their ability to run, lift and climb How do you care for the symptom Condition Detailed description (including restrictions if any) Attach additional paper if necessary I, acknowledge and agree that all information is complete and correct to the best of my knowledge. Parent/Guardian Signature
7 Authorization for Exchange of Information Today s Date Student s Name DOB I, hereby authorize an exchange of information between The Center for Learning Unlimited, 2785 Pacific Coast Highway, Ste G, Torrance, CA Release For Psychiatrist Psychologist School Speech/OT/Tutor Medical Doctor Other Address City State Zip Business Phone Information to be Released Information released shall be limited to the item(s) below: Assessment Results Court Report IEP Report Treatment Progress Police Report School Records Family History Drug/Alcohol Records Records Necessary for Payment Mental Health Information Phone Calls Continuity of Care Other This consent is subject to revocation by the undersigned at any time or within the time specified: Six months One (1) year from dated signature. I understand that I have the right to receive a copy of this authorization upon my request and that I may revoke this authorization at any time. Parent/Guardian Signature Date
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PATIENT INFORMATION PERSON FINANCIALLY RESPONSIBLE LAST NAME FIRST M.I. NAME RELATIONSHIP TO PATIENT PREFERS TO BE CALLED BY MALE FEMALE BIRTH DATE SOCIAL SECURITY NO. BIRTH DATE SOCIAL SECURITY NO. ADDRESS
Plano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074
Locations 1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074 2 East 328 S. Woodcrest Drive, Bloomington, IN 47401 t 812.353.3278 866.353.3278 3 West 2499 W. Cota Drive,
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with
What You Need to Know About LEMTRADA (alemtuzumab) Treatment: A Patient Guide
For Patients What You Need to Know About LEMTRADA (alemtuzumab) Treatment: A Patient Guide Patients: Your doctor or nurse will go over this patient guide with you. It is important to ask any questions
NORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER
GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER Dear Parent, Verde Valley School is committed to providing your child with the best possible care. It is with this goal in mind that the school requires
How To Get A Medical Checkup From A Doctor
Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number:
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
The Dermatology & Laser Group of Irvine, A.M.C. 16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115
16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115 (Please Print) Today s Date / / PATIENT INFORMATION Name Last First M.I. Maiden Name: SS# Email: Mr. Ms.