Microsoft word - enrollment agreement and medical clearance forms sy2011-2012.doc
SANTA BARBARA CATHOLIC SCHOOL
274 W Santa Barbara Ave Ste A, Dededo, Guam 96929-5378 TEL 632-5578 FAX 632-1414 EMAIL info@santabarbaraschool.org WEBSITE http://www.santabarbaraschool.org MEDICAL CLEARANCE FORM FOR SCHOOL ADMISSION Note: Pleasesubmitonorbefore1stdayofschool. STUDENT NAME DATE OF BIRTH ETHNIC GROUP GRADE ENTERING (Please check one) SCHOOL YEAR HOME ADDRESS HOME PHONE MOBILE PHONE FATHER’S NAME MOTHER’S NAME PART 1: PHYSICAL EXAMINATION BLOOD PRESSURE VISION: RT HEARING: RT CHECK EACH LINE Abnormal Not Examined Describe suspicious or abnormal findings General Appearance Skin, Hair, Nails Eyes: External (pupils-cornea) optic fundus Muscle balance Ears: External auditory acuity Tympanic membrane Tympanogram Pure Tone Nose, Mouth Pharynx, Larynx Teeth, Gums Neck, Lymph Nodes Cardiovascular Respiratory Gastrointestinal Genito-Urinary Musculo-Skeletal Scoliosis Screening PART 2: IMMUNIZATION RECORD TOPV, IPV, TOPV, IPV, TOPV, IPV, TOPV, IPV, Td (10 YR) / Tdap Please check one: Perfectly Healthy Specific Problem(s) Noted Handicapped This child is physically fit to participate in physical education and/or athletic events and related activities. Name of Physician (PRINT) Signature SANTA BARBARA CATHOLIC SCHOOL
274 W Santa Barbara Ave Ste A, Dededo, Guam 96929-5378 TEL 632-5578 FAX 632-1414 EMAIL info@santabarbaraschool.org WEBSITE http://www.santabarbaraschool.org MEDICAL INFORMATION TELEPHONE #(S) MOBILE PHONE IS YOUR CHILD ALLERGIC TO ANY MEDICATION? IF YES, WHAT MEDICATION(S)? OTHER ALLERGIES? IS THERE ANY PARTICULAR MEDICAL PROBLEM THAT THE SCHOOL NEEDS TO BE AWARE OF? IF YES, PLEASE EXPLAIN THE MEDICAL PROBLEM BELOW: DO YOU GIVE PERMISSION FOR YOUR CHILD TO BE GIVEN MEDICINE FOR THE FOLLOWING ITEMS BELOW: CHECK ONE PARENT / GUARDIAN PROTOCOL MEDICINE TO BE ADMINISTERED SIGNATURE COUGH or SORE THROAT Cough Drops / Lozenges Ibuprofen (Advil), Acetaminophen MENSTRUAL CRAMPS (Tylenol) EAR ACHE, TOOTACHE, FEVER, HEADACHE Acetaminophen (Tylenol) Peroxide or Betadine (Iodine) / WOUND CARE Over the Counter Ointment IF NO, PLEASE GIVE THE TYPE OF ASPIRIN OR OTHER MEDICATION THAT IS GIVEN TO YOUR CHILD: PROTOCOL MEDICINE TO BE ADMINISTERED COUGH OR SORE THROAT MENSTRUAL CRAMPS EAR ACHE, TOOTACHE, FEVER, HEADACHE WOUND CARE MEDICAL COMMENTS: SIGNATURE OF PARENT OR GUARDIAN
HIGHLIGHTS OF PRESCRIBING INFORMATION • Hypersensitivity Reactions : Use caution when treating patients who are These highlights do not include all the information needed to use hypersensitive to sulfasalazine. Mesalamine-induced cardiac ASACOL HD safely and effectively. See full prescribing information for hypersensitivity reactions (myocarditis and pericarditis) have been ASAC
Summary Resveratrol (3,5,4'-trihydroxystilbene) has been subject to a lot of reasearch lately and a wide range of positive effects have been attributed to this plant phytoalexin. Effects like increased lifespan, cancer prevention, athletic performance enhancement, anti-oxidative, anti-viral, anti- bacterial, anti-inflammatory, cardio protective and neuronal protective effects has been prop
SANTA BARBARA CATHOLIC SCHOOL
SANTA BARBARA CATHOLIC SCHOOL