Health Center Requirements Academy by the Sea/Camp Pacific
|
|
- Jayson Rich
- 8 years ago
- Views:
Transcription
1 Health Center Requirements Academy by the Sea/Camp Pacific The information in this health packet is used to assist our health care professionals in providing proper care for your child. In an effort to avoid any delays for you and your child on registration day please submit all health forms by June 1 st. If you are not able to meet this deadline or if you are registering late please contact Summer Programs immediately so that we may assist in expediting this process. It is advised you keep a copy of these records in case they are not received by mail or fax. Thank you in advance for your cooperation. FORMS MUST BE COMPLETED PER THE FOLLOWING INSTRUCTIONS: Pages 1, 2, and 3 Consent To Treat and Health History To be filled out and signed by parent/guardian. Pages 4 and 5 Physical Examination Forms To be filled out, dated, and signed by a physician. The examination is to have been performed within the past 24 months. Returning participants may use last years physical if it is within 24 months; however the form must be reviewed, signed, and dated for the current year by the physician stating there are no changes in their health. Page 5 Administration of Medication To be filled out, dated, and signed by a physician. This form is required for all participants even if no medications are taken. Participants must list all medications, including all prescription, over-the-counter, and vitamins. All medications are kept and stored in the health center for the safety of all participants. All medications including over the counter and vitamins are to be turned into the Health Center during registration. Please have medications easily accessible to turn in at the registration table, you will not be able to complete the registration process until medications are turned in. Participants are not allowed to self medicate. Keep all medication in its original packaging with the name of the participant, physician, medication, and with direction of dosage. No baggies, pill box containers, or expired medication will be accepted or administered. Samples must be accompanied with written instruction from the physician. Foreign medications must have a written translation with the name of the medication and directions from a physician or pharmacist. Page 6 Notice of Privacy Practice - Academy HIPPA Policy: Parents/Guardians please read and sign. MEDICAL INSURANCE through a U.S. company is required for all participants and proof must be provided for attendance. International participants must purchase the temporary policy provided by Academy by the Sea/Camp Pacific. Domestic participants with no medical insurance must purchase a temporary policy before the enrollment date. If you need assistance in finding an insurance carrier please call the office for a list of carriers. Attach a photocopy front and back of the participant s insurance card. IMMUNIZATION RECORDS are required for all participants by law. Immunizations must be complete and up-to-date. See outline below. Please attach photocopy of the participant s immunization records. INTERNATIONAL PARTICIPANTS must have had a TB test performed in the last year with copies of the results provided to the Health Center. If the TB test is positive, an X-ray report stating an x-ray was performed and is normal must be provided to the Health Center. This is also required for those who have had the BCG Vaccine. If you have any questions regarding the requirements please contact the camp nurse. VACCINE AGE REQUIREMENT Polio doses: 3 if one was on or after the second birthday DTaP, DTP, TD, or DT 7 and older 4 doses: 3 if one was on or after the second birthday. If last dose was before second birthday td booster is needed DTaP, DTP, TD, or 7 grade 1 dose of td booster, if more than 5 years have passed since last dose DT MMR 1-6 and dose on or after 1 st birthday grade MMR 7 grade 2 doses both on or after the 1 st birthday Varicella Out of state 1 dose under 13years 2 doses are needed if immunized on or after 13 th birthday Hepatitis B 7 grade 3 doses The California School Immunization Law allows a child to be exempt from the immunization requirements for personal beliefs or medical reasons. If your child is exempt from immunization, please let us know and we will provide you with a waiver to sign and return. For further information, contact your physician, local health department, or our health center. FOR ALL HEALTH RELATED QUESTIONS PLEASE CONTACT OUR HEALTH CENTER. PHONE: (760) FAX: (760)
2 Consent For Treatment (Page 1 of 6) SELECT THE PROGRAM(S) YOU ARE ATTENDING THIS SUMMER: Academic C-PREP Camp Pacific Surf Camp Sport Camp Camp Challenge CIT The information on this form is part of the enrollment process; it is gathered to assist us in identifying appropriate care. This form is to be filled in by the parent/guardian of participants with the exception of the Physician s Examination section. Male Female Participant: Birth Date / / First Name Last Name M.I. Month / Day / Year Home Address: 1 st Contact - Relationship to Participant: Mother Father Other Ms. Mr. Mrs. First Name Last Name Same as Above Home Address: Home Number Cell Number 2 nd Contact - Relationship to Participant: Mother Father Other Ms. Mr. Mrs. First Name Last Name Same as Above Home Address: Home Number Cell Number 3 rd Contact - Relationship to Participant: Mother Father Other Ms. Mr. Mrs. First Name Last Name Same as Above Home Address: Home Number Cell Number MEDICAL INSURANCE through a U. S company is a mandatory requirement for entrance into the program. Is participant covered by Family medical insurance? Yes No* *Participants with no U.S insurance must obtain coverage prior to the program start date. Domestic participants must obtain a temporary policy through their own means and international participants must enroll in the Academy s temporary medical insurance (see contract for details). A photocopy of the front and back of the participant s insurance card is required for attendance. Insurance Carrier: Policy #: Group #: Address: Phone #: Policy Holder: Family Physician: Phone #: Fax #: Address: It is recommended that all regular dental care be done prior to attending the program. Only emergency dental care will be provided. CONSENT FOR TREATMENT: Permission for Emergency Treatment I hereby give permission to the medical personnel selected by Academy by the Sea/Camp Pacific and/or its authorized representative to: administer medication; order x-rays; order routine tests; render treatment; provide or arrange necessary transportation for the participant; and obtain and release any records and medical information necessary. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Academy and/or its authorized representative to secure and administer treatment, including hospitalization, for the person named above. I authorize any hospital or health care practitioner rendering care necessary under the circumstances for the person names above and to provide copies of medical records and to share clinic information with the Academy and/or its authorized representative. This entire completed from may be photocopied for trips or emergencies off campus. Signature (Parent or Guardian Signature) Date
3 Health History (Page 2 of 6) The following information must be filled in by the parents/guardian. The intent of this information is to provide health care personnel your child s background to provide appropriate care. Provide complete information so we can be aware of the participant s needs. Keep a copy of the completed forms for your records. Please notify health center personnel of any changes prior to arrival. 1 2 Recent injury, illness or infectious diseases? Chronic or recurring illness or condition? YES NO YES NO 23 Migraine headache? 24 Chest pain? Before or after exercise? 3 Hospitalization? 25 Ever passed out during or after exercise? 4 Surgery? 26 Ever been dizzy during or after exercise? 5 Cancer? 27 Heart palpitation or rapid heart rate? 6 Diabetes? 28 Diagnosed with a heart murmur? 7 Mononucleosis in the past 12 months? 29 High blood pressure or high cholesterol? 8 Asthma? Last attack: 30 9 Shortness of breath? 31 Family member or relative die of health problems or sudden death before the age of 50? Chronic diarrhea, constipation or stomach problem? 10 Recurring colds and/or chronic cough? 32 Hernia? 11 Sinus problems? 33 Genital or urinary problems? 12 Hay fever or environmental allergies? 34 Sexually Transmitted Disease? 13 Frequent ear infections? 35 Problems with joints (e.g. knees or ankles)? 14 Seizures? Last episode: 36 Back problems? 15 Other Neurological disorder? 37 Hearing impairment? 16 Head injury? Loss of consciousness? 38 Eye or vision problems? 17 Dizzy or passed out? History of anxiety, depression or emotional difficulties? History of eating disorder? Recent gain/loss of weight? Wear glasses, contacts or protective eyewear? 40 Orthodontic appliance brought to school? 41 Tooth or Gum problems? 20 Trouble sleeping? 42 Skin problems (e.g. itching, rash, acne)? 21 History of bed-wetting? 43 History of drug or alcohol use/abuse? 22 Frequent headaches? (non-migraine) 44 Treated for drug or alcohol use/abuse? 45. Other: * If the candidate wears corrective lenses, please provide a copy of the prescription to facilitate repair or replacement, if needed.
4 Health History (continued ) (Page 3 of 6) Please explain any yes answers, noting the number of the question: Additional information about behavior and physical, emotional, or mental health about which Academy by the Sea/Camp Pacific should be aware: Please indicate any dietary restrictions: Explain any restrictions to activity (e.g. what cannot be done, what adaptations or limitations are necessary): Date of last Tetanus Booster \ \ Date of last Physical \ \ ALLERGIES: List all known allergies and describe reactions and management of the reaction. Medication Allergies List Food Allergies List Other Allergies List (include insect stings, hay fever, asthma, animal dander, etc.) Parent/Guardian Authorization: This health history is correct and complete as far as I know, and the person herein described has permission to engage in all activities except as noted. Print Name Signature Date
5 Physical Examination (Page 4 of 6) PHYSICAL EXAM IS REQUIRED FOR ALL PARTICIPANTS. Exam must be completed within 6 months of enrollment of the current year. A licensed medical practitioner must complete this form within 24 months of program start date. Note: a TB Mantoux Test is required for international participants. Due to the boarding environment, it is recommended that the need for a Meningitis vaccine be discussed at this physical. Physical Examination: Complete a thorough review of systems. Please remark as OK or describe abnormalities in detail. Any necessary treatment or referrals should be completed prior to attendance. Height Weight Blood Pressure Pulse Head Eyes Ears Nose Throat / Mouth Neck Thyroid Neurological Lungs Heart Abdomen Genitalia / Hernia Back Shoulder / Arm Extremities Elbow / Forearm Wrist / Hand Hip / Thigh Knee Leg / Ankle Foot Skin BMI Nutritional Status Anxiety Depression ADD/ADHD Other Psych Problem VISION: R 20/ L 20/ Corrected: Yes No Comments: HEARING: Within Normal Range: Yes No Abnormalities? SCOLIOSIS: Normal: Yes No Abnormal/ Degree of Curvature: IMMUNIZATIONS A copy of the immunization record is mandatory for admission. Please review participant s immunization record and administer any vaccines needed to adhere to the California State guidelines. Date of last tetanus booster: / / Has the participant had any of the following illnesses? Chicken Pox Measles Mumps German Measles Hepatitis TB Mantoux Test (International participants only) A TB test within twelve months is mandatory including those who have had the BCG vaccine. Test Date \ \ Results Reading \ \ (within Hours) Positive Negative induration mm *If skin test is positive a Chest X-Ray must be performed and this area completed Film Date \ \ (do not send copy of x-ray) Impression: Normal Abnormal Participant is free of communicable Tuberculosis: Yes No The participant is under the care of a physician for the following conditions: MEDICATIONS: Does the participant take any medication including routine, OTC S, and supplements? *Yes No (*see pg. 5) Current treatment at the time of this report includes: RESTRICTIONS: Please describe in detail any condition that would prevent or limit full participation in all activities including running, swimming, surfing, sports, and amusement rides: Treatment to be continued while at the Academy: Additional information for health care staff: Is the above applicant able to participate in physical activity? YES NO Physical Exam Date: / / Signature of Physician Date Printed Name Title Address Phone Fax
6 Administration of Medication (Page 5 of 6) Please list ALL medications (including vitamins and over-the-counter drugs) to be taken at the Academy; the name of the medication, the dosage, and the frequency of administration. All medication, including vitamins and over-the-counter are kept and stored in the Health Center. Please keep medications in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), medication name and dosage, participant s name, and expiration date. All prescription medications will need to be refilled by the parent/guardian. The Health Center maintains a supply of over the counter medications for complaints of headache, congestion, cough etc. NO, this person does not take medications on a routine basis. YES, this person takes medications as follows: Med #1 Dosage Specific times taken each day Reason for taking Med #2 Dosage Specific times taken each day Reason for taking Med #3 Dosage Specific times taken each day Reason for taking Med #4 Dosage Specific times taken each day Reason for taking Med #5 Dosage Specific times taken each day Reason for taking Attach additional pages if needed. PHYISCIAN S AUTHORIZATION Signature of Physician Date Printed Name Title Address Phone Fax FOR NURSE ONLY. TO BE COMPLETED BY MEDICAL STAFF AT REGISTRATION. SCREENING RECORD Date Screened Time am pm Medications Received Updates/additions to health history noted: Yes No None required Current health needs identified Observational notes Screened by
7 Notice of Privacy Practice Academy HIPPA Policy (Page 6 of 6) PARTICIPANT Last Name PARTICIPANT First Name THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT ABOVE NAMED PARTICIPANT MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY BEFORE SIGNING. The Academy Health Center, as a provider under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), complies with all regulations designed to protect the privacy of individual health information. Understanding Your Health Record/Information - A record is made of every visit to a health care provider, including the ANA Health Center. Typically this record contains the patient s symptoms, examination/test results, diagnoses, and treatment. This medical or health record is used to plan patient care and permit communication among health professionals, to document care received and verify services provided, to provide data for public health officials, and to improve health services. Your Health Information Rights - Although the health record is the physical property of the AN Health Center or the entity that compiled it, the information belongs to the patient. As the patient s legal guardian you have the right to request a restriction on certain uses and disclosures, to obtain a copy or to request (in writing) to amend the record, to obtain an accounting of disclosures, to request communication of the health information by alternative means, and to revoke your authorization to use/disclose health information except to the extent already done. The Academy Health Center Responsibilities - We are required by law to maintain the privacy of your personal health information and to provide you with this Notice of our legal duties and privacy practices with respect to your personal health information and to have you sign a written acknowledgment that you received this Notice. You will be notified if the ANA Health Center is unable to grant requested restrictions, and accommodate reasonable requests to communicate health information by alternative means or at alternative locations. The ANA Health Center will maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard personal information. The ANA Health Center may disclose information for law enforcement purposes as required by law or in response to a valid subpoena. Persons violating the schools Privacy Policy will be subject to disciplinary procedures. The ANA Health Center reserves the right to change its practices regarding protected health information, in which case a revised privacy notice would be ed or mailed to the address you have supplied. Uses and Disclosures of Health Information - The Academy Health Center personnel will use or disclose patient health information only as needed in treatment, payment, and health care operations. In particular The ANA Health Center may, without specific additional authorization, disclose the patient s health information to any health care provider treating or otherwise rendering professional services to the patient and/or to insurers as necessary to facilitate payment for the patient s health care. Health care providers may, without specific additional authorization, disclose information to The ANA Health Center as needed for the patient s care and treatment. With the exceptions described in this notice and as provided by law, The ANA Health Center will not use or disclose health information without authorization. We may disclose your protected health information in the following situations without your authorization: As required by Judicial or Administrative Proceedings or law enforcement officials We may disclose your protected health information to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or grand jury or administrative subpoena. Public Health Activities - We may disclose your protected health information to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability. Victims of Abuse, Neglect or Domestic Violence If we reasonable believe you are a victim of abuse, neglect or domestic violence, we may disclose your protected health information to a governmental agency, authorized by law to receive reports of such abuse, neglect or domestic violence. Health Oversight Activities - We may disclose your protected health information to a health oversight committee ensuring compliance. Specialized Government Functions - We may disclose your protected health information to units of the government with special functions, such as the U.S. Military or the US Department of State. For More Information or to Report a Problem - If you have questions, please contact the Infirmary at If you believe privacy rights have been violated, you have the right to file a complaint with the Department of Health and Human Services ( ). The Academy Health Center will not retaliate for filing a complaint. Acknowledgement of Authorization to Use and Disclose Health Information I understand and agree that by enrolling at Academy by the Sea/Camp Pacific, the participant named in this Health Form, and by my signature below, I authorize the Academy Health Center personnel to use and disclose the patient s protected health information as needed in treatment, payment, and health care operations. The Academy Health Center personnel may, without my specific authorization, disclose the patient s health information to any health care provider treating or otherwise rendering professional services to him and to insurers as necessary to facilitate payment for services. I understand that information received pursuant to this authorization may be disclosed by the recipient and might lose its protected status. I understand that I may revoke this authorization at any time by written notice to the Academy Health Center. I have read the above and have received a copy of this Notice of Privacy Practice. Signature of Parent/Guardian: Date:
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
More informationNURSING STUDENT HEALTH & IMMUNIZATION RECORDS
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************
More information1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form
Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all
More informationFIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
More informationOhio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST
Ohio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST Page 2 (Physical Examination Form): Page two of this packet is the ONLY
More informationLOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
More information2015 Medical Requirement Forms
PLEASE RETAIN A COPY OF THE COMPLETED HEALTH FORMS FOR YOUR OWN RECORDS 2015 Medical Requirement Forms Ontario Public Health regulations and St. Clair College Policy require health screening for all persons
More informationPATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
More informationNEW STUDENT-ATHLETE MEDICAL HISTORY FORM
Student-Athlete Information NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Name Date Birth SSN Sport Student ID Number Academic Class 1 Personal Physician s Name Phone # Person to Contact In The Event of Emergency
More information1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office)
1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office) Dear FAMILY NURSE PRACTITIONER Student: Congratulations! As Nurse Manager of the Wellness Center I would like to welcome you
More informationPHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider
PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider All full-time, undergraduate students must have a physical exam. PERSONAL DATA Name: Last First Middle Birthdate: Height: Weight:
More informationSTUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students
STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS For Students 1. Fill out the student sections on pages 1, 2 and 5. Take all the pages with you to your physical exam appointment. 2. During your physical exam,
More informationUNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home
More informationGaston College Health Education Division Student Medical Form
Student Name: Date: Gaston College Health Education Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Programs Health and Fitness Science Medical Assisting Nursing Assistant Phlebotomy
More informationEL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS
EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS PHYSICAL EXAMINATION AND IMMUNIZATION REQUIREMENTS In order to comply with the Texas Administrative Code (Title 25 Health
More informationDear Incoming Student:
FOR THE ADVANCEMENT OF SCIENCE AND ART Dear Incoming Student: It is mandatory that you complete and return the enclosed Cooper Union health forms and the New York State required response forms for Meningitis,
More informationSouthwestern College Nursing & Health Occupations Programs
MEDICAL EXAMINATION FORM TO THE PHYSICIAN: Southwestern College requires a physical examination for students enrolling in the Nursing and Health Occupations Programs. A statement of your knowledge of this
More informationWabash Student Health Center
Wabash Student Health Center Information and Instructions for Completing the Student Health Record Dear Incoming Wabash Student and Parent(s): Welcome to Wabash College! In order to make your experience
More informationGreetings from Oklahoma Wesleyan University Student Health Services! STUDENT HEALTH OFFICE AND MEDICAL ATTENTION MEDICAL FORMS PHYSICAL EXAMS
Return all medical forms to: Student Health Department Oklahoma Wesleyan University 2201 Silver Lake Road Bartlesville, OK 74006 Greetings from Oklahoma Wesleyan University Student Health Services! My
More informationPOINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
More informationGREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434
GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434 HEALTH REQUIREMENTS M e d i c a l Assistant Certificate (
More informationAON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?
More informationHealth Information Form for Adults
A. IDENTIFICATION B. EMERGENCY CONTACTS Name (Last) (First) (Middle) Maiden Name Primary Alternate In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Relationship Home Work Home
More informationEnglish Language Fellow Program Health Verification Form
English Language Fellow Program Health Verification Form You are receiving this Health Verification Form (HVF) because your application was reviewed and determined to be eligible for consideration for
More informationHealth Information Form for Adults
A. Identification B. Emergency Contacts Name (Last) (First) (Middle) Maiden Name In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Primary Alternate Relationship Home Work Home
More informationDepartment of State Academic Exchanges Participant Medical History and Examination Form
Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required
More informationNurse Aide. Clinicals ** April 25 April 27, 2016 7:00 A.M. 3:00 P.M. or 6:00 A.M.-2:00 P.M.
Nurse Aide January 11, 2016 February 11, 2016 5:00-9:00 P.M., Monday-Thursday Clinicals ** February 15 17, 2016 7:00 A.M. 3:00 P.M. or 6:00 A.M.-2:00 P.M. March 21, 2016 April 21, 2016 5:00-9:00 P.M.,
More informationPennsylvania School Immunization Requirements
Pennsylvania School Immunization Requirements The Commonwealth of Pennsylvania has minimum immunization requirements for all students. The Pennsylvania Department of Health states that for attendance in
More informationHinds Community College Nursing and Allied Health Programs Health Record Packet
Health Record Packet All Clinical Requirements (including the NAH Health Record Packet) must be submitted by the health profession program s designated date. For students admitted to a new program, failure
More informationKU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION
KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION 1 *Participant: *Name of School: *Name of Coach: *Camper/Commuter: Check One: June Cheer Camp June Dance
More informationYMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM
YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM Branch: North Brooklyn YMCA Camp Site: North Brooklyn Branch Camp Type: PARTICIPANT INFO Child s Name Age D.O.B. Gender Grade in September 2016 School
More informationMedical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
More informationCREATIVE CHILD CENTER ENROLLMENT AND EMERGENCY FORM
: CREATIVE CHILD CENTER ENROLLMENT AND EMERGENCY FORM CHILD S NAME: DATE OF BIRTH: ADDRESS: TOWN: ZIP CODE: HOME PHONE: MOTHER S NAME: E-MAIL: ADDRESS (if different from child): HOME PHONE (if different):
More informationRoswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
More information1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
More informationNew 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.
More information1 5 0 K E N N E D Y D R I V E S O U T H B U R L I N G T O N, V E R M O N T 0 5 4 0 3 8 0 2 4 4 8 9 3 7 0 8 0 2 4 4 8 1 4 1 4 (F)
Worker s Compensation Intake Form : Name: DOB: Social Security Address: City ST Zip Home Phone: Alternate Phone: Occupation: Employer Name: Employer Contact: Do you see a primary care physician for your
More informationAGREEMENT 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.
More informationSummer Youth Musical Theater Workshop Registration Form
2015 Summer Youth Musical Theater Workshop Registration Form PLEASE READ THIS FORM CAREFULLY Please complete the entire registration form and mail it along with your enrollment fee to: Musicals at Richter,
More informationAll Nursing Students. Yearly Physical Exam, Current CPR Card, Personal Health Insurance, Malpractice Insurance (Graduate Students only)
To: Subject: All Nursing Students Yearly Physical Exam, Current CPR Card, Personal Health Insurance, Malpractice Insurance (Graduate Students only) All nursing students must meet the following criteria
More informationPEDIATRIC MEDICAL HISTORY FORM
Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other
More information1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
More informationPatient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
More informationMilford Academy Admissions Office P.O. Box 878, New Berlin, NY 13411 Tel: (607) 847-9260 Fax: (607) 847-9250 www.milfordacademy.
Milford Academy Admissions Office P.O. Box 878, New Berlin, NY 13411 Tel: (607) 847-9260 Fax: (607) 847-9250 www.milfordacademy.org Health Insurance Information Notification (Please Print) This is to inform
More informationRequirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges
To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department
More informationNEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
More informationSPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink)
SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey
More informationAcademy of Art University Sports Medicine Returning Student-Athlete Physical Packet
Attention: Returning Student-Athletes Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet On Behalf of the Sports Medicine Department, we look forward to another healthy
More informationNorth Carolina A&T State University Sebastian Health Center 1601 E. Market Street Greensboro, NC 27411 336-334-7880 Office 336-256-2613 Fax
North Carolina A&T State University Sebastian Health Center 1601 E. Market Street Greensboro, NC 27411 336-334-7880 Office 336-256-2613 Fax GUIDELINES FOR COMPLETING THE REQUIRED MEDICAL HISTORY PACKET
More informationNORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM
NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: This is a screening examination for participation in sports. This does not substitute for a
More informationNOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction this portion of the examination determines the best lens correction
More informationAPPLICATION FOR THE RN to BSN PROGRAM NAME: ADDRESS:
APPLICATION FOR THE RN to BSN PROGRAM PLEASE PRINT CLEARLY NAME: ADDRESS: Please check Campus you wish to attend: Rutgers Camden: Atlantic Cape Community College: Camden County College at Blackwood: Home
More informationHOUGHTON COLLEGE & CSEHY SUMMER SCHOOL OF MUSIC MEDICAL RECORD & WAIVER FORMS
HOUGHTON COLLEGE & CSEHY SUMMER SCHOOL OF MUSIC MEDICAL RECORD & WAIVER FORMS COMPLETION AND RETURN OF THIS FORM TO THE CAMP DIRECTORS IS REQUIRED FOR ADMISSION TO CAMP. Either Mail This Completed Form
More informationPrint Provider Packet and schedule an appointment with your healthcare provider to complete the packet.
Due Dates: Incoming Fall Students July 15 th Incoming Spring Students December 15 th Incoming Summer Students July 15 th THESE FOLLOWING ARE REQUIRED BY NJ STATE LAW AND ROWAN UNIVERSITY POLICY. FAILURE
More informationTrinitas School of Nursing Health Clearance Information
Trinitas School of Nursing Health Clearance Information Students are required to have health clearance before they are allowed to register for NURE 131 and higher courses. All NURE 132, NURE 231, NURE
More informationHealth Form Instructions
Health Form Instructions 888 272-7881 Fax 802 258-3509 studyabroad@sit.edu www.sit.edu/studyabroad The Health Form must be submitted within TWO WEEKS of offer of admission. If this is not possible, then
More informationDear Concordia University Athletes and Parents,
Dear Concordia University Athletes and Parents, It is with great anticipation that we look forward to the coming athletic year where each athlete will be involved in competition as a representative of
More informationHow To Get Immunizations At Clemson
Immunization Forms Welcome to Clemson University! We are glad you have chosen us to meet your higher education goals. The University requires a complete immunization record to be on file at for all students.
More informationChoptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL
Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline County Public School system, your child has access to the School-Based
More informationPATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Date Patient s Name Last First Initial Street Address City State Zip Code Phone No. Date of Birth Age Sex Married/Single Family Doctor Patient s Social Security No. - - Referring
More informationGaston College Health and Human Services Division Student Medical Form
Student Name: : Gaston College Health and Human Services Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Technician and Dietary Manager Health and Fitness Science Medical Assisting
More informationFall Registration Checklist
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
More informationCAMPER HEALTH HISTORY FORM 1
CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Dates will attend camp: from to
More informationWorkman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
More informationWELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
More informationCaribbean School of Medical Sciences, Jamaica Medical Student Health Services 8 Waterloo Rd, Kingston Jamaica. Dear Prospective Student,
Caribbean School of Medical Sciences, Jamaica Medical Student Health Services 8 Waterloo Rd, Kingston Jamaica Dear Prospective Student, CSMSJ would like to welcome you to the Caribbean School of Medical
More informationPlease fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
More informationCopayment Is Due At Time Of Visit. Self-pay (payment due at time of service)
REGISTRATION FORM Please present your insurance card and photo ID at time of check-in. Settlement of patient financial responsibility is expected at time of service. Copayment Is Due At Time Of Visit.
More informationPATIENT INFORMATION FILL OUT ALL ITEMS
PATIENT INFORMATION FILL OUT ALL ITEMS FAILURE TO COMPLETELY FILL OUT THIS FORM MAY RESULT IN YOU BEING BILLED IN FULL Patient Last Name: First: MI:. Address:. Date of Birth: Gender: M or F Marital Status:
More informationHoly Family University, Student Health Services, Directions for Completion of Health Packet
1 Holy Family University, Student Health Services, Directions for Completion of Health Packet All forms are to be returned to Health Services by Summer Orientation for the Fall Semester and the first day
More informationWelcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
More informationDear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality
Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality pediatric care. Additionally, we promise to offer superior
More informationAll forms are to be completed and returned to: The University of Denver Attn: Sports Medicine, Room 1312 2201 E. Asbury Ave. Denver, CO 80208-3200
Julie Campbell Director of Sports Medicine (303) 871-3918 Office (303) 871-3666 Fax jcampbel@du.edu To: Re: Returning Student-Athletes 2014-2015 Sports Medicine Medical Information Packets Date: Thursday,
More information2014-15 Point Park University Medical Packet CONTENTS
2014-15 Point Park University Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2014-15 year. Please return all completed forms
More informationWestern Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
More informationNorth Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:
More informationEntrance Health Certificate
Entrance Health Certificate 1 Wheelock College Student Health Service ENTRANCE HEALTH CERTIFICATE The Entrance Health Certificate must be completed in its entirety and brought with you to Boston. Admission
More informationThe Immunization Office, located in the Student Health Center, is open year round to administer needed immunizations at a nominal fee.
Student Health Services 2815 Cates Avenue Raleigh, NC 27695-7304 919-515-2563 healthcenter.ncsu.edu The Immunization Record Form is designed to collect information about your current immunization status.
More informationDr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax
Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments
More informationMOTORSPORT PERSONAL ACCIDENT PROPOSAL FORM
Hanleigh Management Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey 07677 Phone: (201) 505-1050 or (800) 443-2922 / Facsimile: (201) 505-1051 www.hanleighinsurance.com MOTORSPORT PERSONAL ACCIDENT
More informationLEHMAN COLLEGE DEPARTMENT OF NURSING ANNUAL HEALTH CLEARANCE REQUIREMENTS
ANNUAL HEALTH CLEARANCE REQUIREMENTS Each student in the Department of Nursing must have current health clearance prior to each clinical nursing course (NUR 301, 303, 304, 400, 405, 409). Health clearance
More informationHow To Fill Out A Health Declaration
The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
More informationHUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK HUNTER-BELLEVUE SCHOOL OF NURSING HEALTH REQUIREMENTS AND CLINICAL PRACTICE CLEARANCE
HUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK HUNTER-BELLEVUE SCHOOL OF NURSING HEALTH REQUIREMENTS AND CLINICAL PRACTICE CLEARANCE All undergraduate students entering clinical courses are required
More informationCHILDREN ON CAMPUS PARTICIPATION AGREEMENT AND WAIVER FORM
CHILDREN ON CAMPUS PARTICIPATION AGREEMENT AND WAIVER FORM PROGRAM/CAMP INFORMATION Parents and legal guardians are responsible for carefully reviewing all program materials and for selecting programs
More informationLander University Athletic Training Education Program Application Outline
Lander University Athletic Training Education Program Application Outline The following items and information is required for admission into the Lander University Athletic Training Education Program (ATEP).
More informationPortland State University Sports Medicine Returning Student Athlete Health Report Form
Portland State University Sports Medicine Returning Student Athlete Health Report Form All the following forms must be completed and submitted to the Sports Medicine Department annually. It needs to be
More informationNew Patient Information Form
PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?
More informationLake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600
PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company
More informationUniversity of Hawai i at Mānoa University Health Services Mānoa 1710 East-West Road, Honolulu, Hawai i 96822 (808) 956-8965 FAX: (808) 956-3583
University of Hawai i at Mānoa 1710 East-West Road, Honolulu, Hawai i 96822 (808) 956-8965 FAX: (808) 956-3583 Dear Entering Students: Welcome to University of Hawai i at Mānoa! The (UHSM) is located on
More informationFAMILY CONTACT INFORMATION
FAMILY CONTACT INFORMATION -------------------- PLEASE COMPLETE THIS FORM IN BLACK INK ONLY -------------------- Date Account # Children Names DOB Gender School Goes By Cell Phone # Email Address Please
More informationEmergency Medical Technician
Emergency Medical Technician Admission Requirements EMERGENCY MEDICAL TECHNICAL IMPORTANT: PLEASE READ CAREFULLY Classes are held on Tuesday and Thursday nights from 5:00 p.m. until 9:00 p.m. All classes
More informationMEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
More informationSan Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your
More information11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
More informationRegistration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015
Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015 TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN. Date of Program Please print in ink or type, and
More informationNAME: (PRINT) First Last. College M#:
SPORT (s): NAME: (PRINT) First Last College M#: MONTGOMERY COLLEGE SPORTS MEDICINE PACKET INSTRUCTIONS: - 7/11 - DO NOT remove any papers this includes the four physical exam pages! - If downloading from
More informationAdult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
More informationHEALTH SCIENCE PROGRAMS Chipola College Marianna, Florida 32446 PARAMEDIC CERTIFICATE PROGRAM
Revised 3/05 HEALTH SCIENCE PROGRAMS Chipola College Marianna, Florida 32446 PARAMEDIC CERTIFICATE PROGRAM The class meets on Tuesday, Wednesday and Thursday from 12:00 p.m. until 6:00 p.m. The classes
More informationTHE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP
THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP 2011 SUMMER FASHION PROGRAM STUDENT APPLICATION CHECKLIST To apply for the Summer Fashion Program, please submit the required documents to The Center for Global
More informationPatient Information. Date: Home Phone: Work Phone: Cell: Address: City: State: Zip: Whom may we thank for referring you:
DANIEL LEE, D.D.S. Prev entive Res torative Cosmetic Dentistry Patient Information Date: Home Phone: Work Phone: Cell: Name: Social Security Number: - - Email: Address: City: State: Zip: Sex: M F Birthdate:
More information