Vision and Hearing Program Consent for Services. I, the parent/legal guardian of, give consent Please print name of child
|
|
|
- Juana Cárdenas Ferreyra
- hace 5 años
- Vistas:
Transcripción
1 Vision and Hearing Program Consent for Services I, the parent/legal guardian of, give consent Please print name of child for the Cook County Department of Public Health to provide vision and/or hearing screening to my child at his/hers school/day care center. I understand that a copy of the screening results will be provided to me by the school/day care center. The school/day care center will also keep a copy of the results on file. I further understand that I am responsible to provide for all follow- up for findings as recommended by the Cook County Department of Public Health. Parent/Legal Guardian Print Name Date Signature of Parent/Legal Guardian Revised 12/3/2014 VH- 676
2 Programa de control de la visión y audición Autorización para servicios Yo, padre/tutor legal de, autorizo Por favor, escriba el nombre del niño en letra de molde al Departmento de Salud Pública del Condado de Cook a realizer los estudios de control de la visión y/o audición a mi hijo/a en la escuela/guardería infantil a la que asiste. Entiendo que la escuela/guarderia infantil me entregará una copia del resultado de los estudios. Además, la escuela/guardería conservará una copia de los resultados en sus archivos. Entiendo tambien que soy responsible de realizer el seguimiento recomendado por el Departamento de Salud Pública del Condado de Cook a partir de los resultados de los estudios. Padre/tutor legal Nombre en letras de molde Fecha Firma del padre/tutor legal Revised: 12/3/2014 VH- SP- 676
3 Elementary Only School: Date: School Address: Grade: Directory/Teacher: Room #: Child's Name Elementary Only Hearing Vision Age Sex Scrn Re-Scrn Comments Scrn Re-Scrn Comments /24/13 VH-682
4 VISION AND HEARING PROGRAM EYE AND EAR HISTORY CHILD S NAME: SEX: AGE: DATE OF BIRTH: PARENTS: ADDRESS: TELEPHONE: ( ) CITY: STATE: ZIP CODE: Please answer the following questions accurately. The information will help the technician evaluate screening results. FAMILY EYE HISTORY Yes 1. Has your child ever been seen by an eye doctor? If Yes, when? Why? No 2. Does your child wear glasses?. 3. Have you noticed signs which might indicate eye difficulty?. 4. Do the child s eyes look crossed, especially when tired or ill? 5. Do any family members have a crossed eye?... Parent? Sister/Brother? 6. Has the child had surgery for crossed eyes?. FAMILY EAR HISTORY Yes 1. Has your child ever had a hearing test? No 2. Has your child ever had ear infections, earaches, or running ears?.. 3. Does your child have allergies? 4. Has your child seen a doctor for ear problems? 5. Does your child have a hearing loss? 6. Does child have tubes or is he/she currently under care for ear problems?.. Name of ear doctor: COMMENTS: P F CNT P F CNT REF H / 2 V / 2 DATE: DATE: SCREENING SITE: TECHNICIAN: 2/4/2010 VH-650
5 PROGRAMA DE LA VISIÓN Y LA AUDICIÓN ANTECEDENTES VISUALES Y AUDITIVOS NOMBRE DEL NIÑO: SEXO: EDAD: FECHA DE NACIMIENTO: PADRES: DOMICILIO: TELÉFONO: ( ) CIUDAD: ESTADO: CÓDIGO POSTAL: Por favor, responda las siguientes preguntas con precisión. Estos datos ayudarán al técnico a evaluar los resultados de los estudios. ANTECEDENTES VISUALES DE LA FAMILIA 1. Su hijo fue examinado alguna vez por un médico oftalmólogo? Si la respuesta es Sí, cuándo? Por qué? 2. Su hijo usa anteojos?.. 3. Usted ha advertido señales de que su hijo puede tener problemas de visión? 4. Sus ojos se ven cruzados, en especial cuando está cansado o enfermo? 5. Algún miembro de la familia tiene estrabismo?..... El padre o la madre? La hermana o el hermano? 6. El niño ha sido operado por estrabismo?. Sí No ANTECEDENTES AUDITIVOS DE LA FAMILIA Sí No 1. Alguna vez le han hecho un análisis de la audición a su hijo? 2. Su hijo tuvo alguna vez infecciones, dolor o sangrado en los oídos? Su hijo tiene alergias? Ha llevado a su hijo al médico por problemas en los oídos?.. 5. Su hijo tiene audición disminuida?. 6. Su hijo tiene tubos (o diábolos) colocados o está en tratamiento por problemas en los oídos?.. Nombre del otorrinolaringólogo: OBSERVACIONES: P F CNT P F CNT REF H / 2 V / 2 FECHA: FECHA: LUGAR DEL ESTUDIO: TÉCNICO: 2/4/2010 VH-650S
6 SCREENING DATE: Vision and Hearing Screening Program (K-6 th Grade Use Only) NAME: PARENT/GUARDIAN: ADDRESS: CITY: PHONE: ZIP: BIRTHDATE: SCHOOL: GRADE: ROOM: ******************************************************************************* I. Muscle Balance: Rescreen Date: Near In Out In Out Far In Out In Out II. Visual Acuity Right Right Left Left III. Hyperopia (+ lens) Right Right Left Left ********************************************************************************* PASSED RESCREEN REFFERED ABSENT ABSENT FOR RESCREEN CNT WEARING GLASSES / UNDER DR S CARE DATE OF LAST EXAM GLASSES REFERRAL COMMENTS: ********************************************************************************* PASS HEARING RESCREEN: RESCREEN DATE: PASS REFERRED: SCREENING TECHNICIAN: VH-669 2/4/2010
7 Vision and Hearing Screening Program (7 th & 8 th Grade Use Only) SCREENING DATE: NAME: PARENT/GUARDIAN: ADDRESS: CITY: PHONE: ZIP: BIRTHDATE: SCHOOL: GRADE: ROOM: ****************************************************************************** Left Middle Right NEAR BRL / / FAR BRL / / Rescreen Left Middle Right NEAR BRL / / DATE: FAR BRL / / ******************************************************************************** PASS RESCREEN REFERRED PASS RESCREEN ******************************************************************************** WEARING GALLSES / UNDER DR S CARE DATE OF LAST EYE EXAM: WEARING CONTACT LENS: DATE OF LAST EXAM: GLASSES REFERRAL / COMMENTS: REFERRAL TO UPDATE PRESCRIPTION AND MEDICAL RECORD: COMMENTS: HEARING SCREENED Passed Rescreen Referred 12/3/2014 VH-668
8 Date VISION EXAMINATION REPORT White Doctor s Referral Canary File Name Birth Date Sex Grade Parent or Guardian Address Phone County Testing Location Testing Agency Tester TEST GIVEN 1. Instrument Used a. Visual Acuity b. Plus Sphere c. Muscle Balance d. Near and Far Binocular Vision e. Other: TO THE DOCTOR TO BE COMPLETED FOLLOWING SCREENING REASON FOR REFERRAL 1. Visual Acuity 2. Plus Sphere 3. Muscle Balance Phoria 4. Near and Far Binocular Vision Fusion SYMPTOMS NOTED 1. Academic Achievement 2. Observable Signs: CHILD WEARING GLASSES OR UNDER CARE Children wearing glasses or under care are not screened as part of the routine vision screening program. Observations by screening technicians possibly indicate the following: Frames broken / too small Two years since last examination Lenses scratched / broken Other: Name (Last) (First) (Initial) TO BE COMPLETED BY EXAMINING DOCTOR UNCORRECTED (1) VISUAL ACUITY DISTANCE (2) BEST CORRECTED VISUAL ACUITY RIGHT LEFT RIGHT LEFT (3) Ocularmotor Assessment (4) Diagnosis PLEASE CHECK IF APPROPRIATE: Treatment recommended Medical Glasses Contact Lenses Other: Corrective lens prescribed Constant Wear Near Vision only Far Vision only May be removed for physical education Visual field restriction Amblyopia exists (5) Comments Muscle imbalance exists Close work may be difficult or cause fatigue Please leave All 3 COPIES ATTACHED FOR THE DOCTOR TO FILL OUT AND RETURN ALL 3 COPIES TO: Cook County Department of Public Health, HSDM 1701 S. 1 st Avenue, 1 st Floor Maywood, Illinois CONSENT OF PARENT OR GUARDIAN I agree to release the above information on my child or ward to appropriate school or health authorities. PARENT OR GUARDIAN S SIGNATURE IDPH V-4 IL Revised Please print or stamp Doctors Address City Date of Examination Preferential seating needed Re-examination advised Six months Twelve months Other: DOCTOR S SIGNATURE Name
9
10
11
12
13
14
15
Vision and Hearing Program Consent for Services. I, the parent/legal guardian of, give consent Please print name of child
Vision and Hearing Program Consent for Services I, the parent/legal guardian of, give consent Please print name of child for the Cook County Department of Public Health to provide vision and/or hearing
Vision and Hearing Program Consent for Services. I, the parent/legal guardian of, give consent Please print name of child
Vision and Hearing Program Consent for Services I, the parent/legal guardian of, give consent Please print name of child for the Cook County Department of Public Health to provide vision and/or hearing
Phelan Language Academy DUAL LANGUAGE IMMERSION Providing a World of opportunities for students DUAL LANGUAGE IMMERSION APPLICATION FORM
Phelan Language Academy DUAL LANGUAGE IMMERSION Providing a World of opportunities for students DUAL LANGUAGE IMMERSION APPLICATION FORM PLEASE NOTE: Applications need to be received by the due date and
Employee s Injury Report / Informe de lesión de empleado
Claims Administrative Services Phone: 800-765-2412 Fax: 903-509-1888 501 Shelley Drive Claims Administrative Services, Inc. Tyler, Texas 75701 Our reputation for excellence is no accident. / Nuestro prestigio
Barbara Quaid. March 1, Dear Ventura County Teachers:
March 1, 2018 Dear Ventura County Teachers: The Ventura County Fair invites students to earn free carnival rides through our reading program, Read & Ride for local kindergarten through 8 th grade students.
WHCS. Washington Heights Choir School Escuela de Coro de Washington Heights. an after school program un programa después de la escuela
WHCS Washington Heights Choir School Escuela de Coro de Washington Heights an after school program un programa después de la escuela APPLICATION FORM FORMULARIO DE INSCRIPCIÓN Please print neatly and complete
Application for Admissions School Year: Class of 2020
For Office Use Only: Date Received: Administration Fr. Tom Schrader, President Ms. Karen Hopson, Principal Mr. Michael Beaven, Vice Principal/ Dean of Students 708 N. 18th Street Kansas City, KS 66102
1. When you suspect a child has scabies, call the parent and share your concern. Check all children for further cases.
Page 1 of 5 SCABIES PROCEDURE Scabies is a skin infestation caused by a human mite. For description and period of communicability refer to Scabies in the Infectious Disease Control Guide for School Staff.
Employer Employer Address Phone. Phone: Home Work Cell
PATIENT REGISTRATION Last Name First Name MI Date of Birth Age Social Security # Gender Marital Status Address Street Apt# City State Zip Phone: Home Work Cell E-Mail Occupation Retired: Yes No Employer
Transitional Kindergarten Program Parent Request
Date Received: / / Time Received: am / pm FOR OFFICE USE ONLY Transitional Kindergarten Program Parent Request Child s Name: (Please Print) First Middle Last Birth Date: / / Sex: M F Month Day Year Home
Current Grade Date of Birth / / Grade entering
Frontier School of Innovation 6700 Corporate Dr. Phone: 816-363-1907 (E): 816-241-6202 (MS) Fax: 816-363-1165 (E): 816-241-6207 (MS) http://www.kcfsi.org STUDENT INFORMATION Frontier STEM High School 6455
Inspire.Innovate.Engage KINDERGARTEN PRE-REGISTRATION
1 2018-2019 KINDERGARTEN PRE-REGISTRATION Packet Must Be Returned By February 1 st, 2018 for Program Consideration District Office, Door A-2, 1936 Green Bay Rd, Highland Park, IL 60035 Monday Thursday
For Parents and Caregivers
Who Qualifies How to Enroll WHO QUALIFIES FOR WIC: HOW TO ENROLL IN WIC: You must Bring the infant or child to the WIC office to complete initial enrollment. If the infant or child can t be there because
Registration /Formulario de Inscripción
Catechesis of the Good Shepherd/Catequesis del Buen Pastor Registration 2017 2018/Formulario de Inscripción Family must be registered and actively involved in our Parish to be able to participate in our
Sample Parental Consent Letters
Sample Parental Consent Letters 2015-16 The following links provide sample parental consent letters that clients are welcome to edit for their own purposes. Under applicable federal, state, and local laws,
FERRIS INDEPENDENT SCHOOL DISTRICT NONRESIDENT STUDENT REQUEST TO TRANSFER INTO THE DISTRICT SCHOOL YEAR
FERRIS INDEPENDENT SCHOOL DISTRICT NRESIDENT STUDENT REQUEST TO TRANSFER INTO THE DISTRICT SCHOOL YEAR 2018-2019 1. STUDENT S NAME: 2. CURRENT ADDRESS: 3. SCHOOL DISTRICT IN WHICH THE STUDENT RESIDES:
Eligibility List (EL) Application
Division of Early Learning Services Early Care and Education Parent(s) Information First Name: Middle Initial (MI): Last Name : Male Female Male Female Birth Date: Work Phone: Cell/Message: E-mail: Married:
STUDENT RESIDENCY QUESTIONNAIRE/AFFIDAVIT
STUDENT RESIDENCY QUESTIONNAIRE/AFFIDAVIT This document is intended to address the McKinney-Vento Assistance Act. Your answers will help determine documents necessary to enroll your child quickly and determine
Harden Middle School AVID APPLICATION
Incoming 7 th Date Submitted: Time: Person at HMS who received it: Harden Middle School AVID APPLICATION Your student is being recommended to participate in the AVID program at Harden Middle School. AVID
Newborn Hearing Screening Script for Talking with Parent(s)
SCREENING BABY: Informing Parents of the Screen: Hi! Congratulations on the birth of your baby. You have received information that we provide hearing screening to all babies. We are going to screen your
NUEVOS ESTUDIANTES PAQUETE DE INSCRIPCIÓN
BIENVENIDOS A PAVE SCHOOLS! NUEVOS ESTUDIANTES PAQUETE DE INSCRIPCIÓN Apellido Del Estudiante Primer Nombre Del Estudiante Fecha De Nacimiento Completar los formularios y presentar los documentos requeridos:
TRENTON BOARD OF EDUCATION ''Children Come First, Los Niños son Primeros." Lucy Feria Micah Bradley-Freeman, MSN RN Interim Superintendent of School Supervisor of Nurses 609.656.4900 609.989.2682 fax lferia@trenton.k12.nj.us
PLEASE RETURN THIS SIGNED FORM TO OUR OFFICE, WE WILL MAKE YOU A COPY AND PLACE IT IN YOUR FAMILY FILE.
AGREEMENT 1. NON REFUNDABLE Registration fee of $100. 2. Full time Children s Center accounts are billed each month. Payment is due every 10th or 25th of the month. Each family is required to sign up Smart
CUESTIONARIO Encuesta sobre personas con problemas de visión. Instituto de Estadísticas de Puerto Rico
CUESTIONARIO Encuesta sobre personas con problemas de visión 17 de octubre 2011 Cuestionario Trasfondo Este documento contiene el cuestionario de la Encuesta sobre las personas con problemas de visión.
PARENT / GUARDIAN INFORMATION. FIRST NAME / PRIMER NOMBRE* LAST NAME / APELLIDO* BIRTHDATE mm/dd/yyyy / FECHA DE NACIMIENTO mm/dd/aaaa
PARENT NAME / PADRE NOMBRE PARENT ID ** / ID DE PADRE *** PARENT / GUARDIAN INFORMATION **If you were given a login that looks like this: 12345@osd Please enter just the numbers here. *** Si le dieron
LOS ANGELES UNIFIED SCHOOL DISTRICT STUDENT EMERGENCY INFORMATION FORM Parent Information: Please fill out completely and sign where indicated. In a major emergency, it is school district policy to retain
Requesting Accommodations SAT and ACT. Sign and return the Parent permission form to the SSD Coordinator
Requesting Accommodations SAT and ACT SAT Sign and return the Parent permission form to the SSD Coordinator SSD Coordinator submits information online to College Board The deadline for accommodations approval
Informacion Basica de el paciente
Informacion Basica de el paciente Cash Fecha: Apellido: Nombre: Inicial: Direccion: Pueblo: Estado: Zip: Telefono de la casa o celular: Telefono del trabajo: Numero de seguro social: Fecha de nacimiento:
(School District Name) (School District Address) (School District Phone Number) HOME LANGUAGE SURVEY
HOME LANGUAGE SURVEY STAFF MEMBERS: This form must be completed for all students registering in To Be Completed by Parent of Guardian: Student Name: Date of Birth Last First Middle Mo. Day Yr. Parent(s)
Gender: Female Ethnicity: Birthdate: (Mon/Date/Year) (Number) (Street) (City) (Zip)
Application Form Due March 17 th, 2017 Student's Name (Last, First): Gender: Female Ethnicity: Birthdate: Male (Mon/Date/Year) Home Address: (Number) (Street) (City) (Zip) Phone Number: ( ) Alt. Phone
violencia domestica? Si No Ciudad: Estado: Código Postal: Si hay problemas de violencia domestica, por favor diríjase a la sección #7f abajo.
Por favor escriba claramente con letra de molde dentro de la cuadricula: Información del solicitante: Soy la persona que proporciona cuidados o el padre que no tiene custodia 1. Información de la persona
New Student/Parent Enrollment Instructions
New Student/Parent Enrollment Instructions Instruciones para Inscripción de Nuevo Estudiante/Padre al distrito 1) If you don t have a Skyward user id and password and have never had a student at LISD,
ANAPHYLAXIS/ALLERGIC REACTION INFORMATION FROM PARENT Student Name Birth Date School Teacher/grade Parent/Guardian Phone (H) Phone(W) Phone(Cell) Parent/Guardian Phone (H) Phone(W) Phone(Cell) Emergency
Client: Client Type:
H3018 Usage/Verification of Travel by Mass Transit to Healthcare Services To or to the Parents or Guardian of: ADDRESS Return the Enclosed Form to: Texas Medicaid Healthcare Partnership PO Box 203188 Austin,
January 1, Paula C. Holder 1234 Main St Any Town, USA Dear Member,
January 1, 2019 Paula C. Holder 1234 Main St Any Town, USA 12345 Dear Member, Your Medicare Part D plan, Teamster Plus Medicare Part D (PDP) provides a Medication Therapy Management (MTM) program at no
Encl.: Teacher/Teacher Assistant Information Request Form
To: All Parents/Legal Guardians in Title I Schools From: Charlotte-Mecklenburg Schools Title I Department Date: September 27, 2017 Subject: Right to Know Notification to Parents of Teacher and Teacher
Civil Rights Complaint Form
Civil Rights Complaint Form Title VI of the 1964 Civil Rights Act and related non-discrimination statutes and regulations require that no person in the United States shall, on the ground of race, color,
Windham Early College Opportunity Application for Admission
Windham Early College Opportunity Application for Admission Thank you for your interest in the Windham Early College Opportunity program at Windham High School. You may hand-deliver or mail the completed
HIDALGO ISD GIFTED/TALENTED PROGRAM PUBLIC ANNOUNCEMENT OF REFERRAL PERIOD HIDALGO ISD PROGRAMA PARA ESTUDIANTES DOTADOS/TALENTOSOS
Public Notice HIDALGO ISD GIFTED/TALENTED PROGRAM PUBLIC ANNOUNCEMENT OF REFERRAL PERIOD Hidalgo is now accepting referrals for students who may need Gifted/Talented Services for the school year. This
Old Mission San Juan Bautista Religious Education Registration Form Office Phone: (831)
Old Mission San Juan Bautista Religious Education Registration Form Office Phone: (831) 623 4178 faithformation@oldmissionsjb.org Today's Date: Amount Paid: Installments: RCIA: 1st Yr [ ] 2nd Yr [ ] 1st
LONG BEACH UNIFIED SCHOOL DISTRICT
LONG BEACH UNIFIED SCHOOL DISTRICT Parent/Guardian Complaint Concerning District Personnel Pursuant to Education Code Section 35160.5, the District has a carefully defined procedure for processing complaints
CHANGE OF HOUSEHOLD COMPOSITION PACKET INSTRUCTIONS TO REMOVE A MEMBER
CHANGE OF HOUSEHOLD COMPOSITION PACKET INSTRUCTIONS TO Participant: REMOVE A MEMBER In an effort to ensure you and your household are served in a timely manner, we are requesting that you completely fill
Going Home. Medicines. Pain. Diet
Going Home After an illness or injury, some things may change in your life. Make sure you and your family know the answers to these questions before you go home from the hospital. Medicines Am I taking
Denver District Court Tribunal de distrito de Denver Court Address: Dirección del tribunal: 1437 Bannock Street, Room 256, Denver, CO 80202
Denver District Court Tribunal de distrito de Denver Court Address: Dirección del tribunal: 1437 Bannock Street, Room 256, Denver, CO 80202 In re: En referencia: The Marriage of: Al matrimonio de: The
Jennifer Bellinger ORHS Principal. October 16, 2017
October 16, 2017 Dear Parent/Guardian of, Oak Ridge High School is dedicated to providing additional academic instruction designed to increase students academic achievement on grade level state standards.
Escuelas Condado Rutherford Matricula de Kindergarten/Hoja de Información del Estudiante
Nombre del Maestro/a Kindergarten 2018 Escuela Escuelas Condado Rutherford Matricula de Kindergarten/Hoja de Información del Estudiante Para asistirnos a mantener nuestros récords correctos, por favor
OCONEE COUNTY MENTOR PROGRAM. Permission Form Packet
OCONEE COUNTY MENTOR PROGRAM Permission Form Packet PARENT INFORMATION/EXPECTATIONS Your child has been selected to participate in the Oconee County Mentor Program. This program was established to provide
Cuestionario Médico Edades de 13 en adelante. Medical Questionnaire Ages 13 and Above
Cuestionario Médico Edades de 13 en adelante Medical Questionnaire Ages 13 and Above Nombre del adolescente: Cuestionario llenado por: Questionnaire filled out by Relación con el adolescente: Relationship
I understand that I must request that this waiver be reconsidered annually, each school year. Parent/Guardian Signature: Date:
Page 1 of 7 PARENTAL EXCEPTION WAIVER EDUCATION CODE 311(a): Children who know English (Exhibit 1) Name: School: Grade: Date of Birth: Language Designation: My child possesses good English language skills
Continúa a la siguiente página
ASOCIACION DE PROGRAMAS DE OPPORTUNIDAD PARA TRABAJADORES AGRICOLAS (AFOP) CONCURSO DE ARTE PARA NINOS/AS DE TRABAJADORES AGRICOLAS MIGRANTES O TEMPORALES 2017 CRECIENDO EN LOS CAMPOS QUE ALIMENTAN A AMÉRICA
FORMAT B2 SPEAKING EXAM
FORMAT B2 SPEAKING EXAM PRODUCCIÓN ORAL 25% 1 2 3 El examinador, de manera alternativa, hará preguntas a los dos alumnos. (4-5 min en total) Cada candidato tiene 15 segundos para preparar un tema determinado
Level 1 Spanish, 2013
90911 909110 1SUPERVISOR S Level 1 Spanish, 2013 90911 Demonstrate understanding of a variety of Spanish texts on areas of most immediate relevance 9.30 am Tuesday 3 December 2013 Credits: Five Achievement
Home Access Center Matriculación Electrónica Verificación Del Estudiante
Home Access Center Matriculación Electrónica Verificación Del Estudiante Los padres o tutores que tienen una cuenta de correo electrónico existente en los archives de la escuela de su hijo/a recibirán
Annual Latino Youth & Parent Leadership Conference for:
Annual Latino Youth & Parent Leadership Conference for: Leadership Skills Positive Self-Esteem Career Awareness Napa County 8th - 12th Grade Students & Parents Saturday, April 25, 2015 8:00 a.m. - 2:00
LAW OFFICE OF THOMAS & THOMAS Imperial Valley Dr, Suite 137 Houston, TX
Today s Date: Fecha de Hoy: Name: Nombre: Address: Dirección: LAW OFFICE OF THOMAS & THOMAS 16630 Imperial Valley Dr, Suite 137 Houston, TX 77060 www.thomasandthomasattorneys.com CLIENT INTAKE INFORMACIÓN
El Abecedario Financiero
El Abecedario Financiero Unidad 4 National PASS Center 2013 Lección 5 Préstamos Vocabulario: préstamo riesgocrediticio interés obligadosolidario A lgunavezpidesdineroprestado? Dóndepuedespedirdinero prestado?
SCHOOL ANAPHYLAXIS ACTION PLAN * * * * * * * * * * * * * * * * * * * * * * EMERGENCY PLAN * * * * * * * * * * * * * * * * * *
SCHOOL ANAPHYLAXIS ACTION PLAN (To be completed at the beginning of each school year and kept on file with the school nurse or office of the principal) Student s Name: Grade: DOB: School Campus: School
Circuit Court for TRIBUNAL DE CIRCUITO DE
Circuit Court for TRIBUNAL DE CIRCUITO DE City or County (Ciudad o Condado) Case No. Name (Nombre) vs. (contra) Name (Nombre) Street Address (Dirección) Apt. # Street Address (Dirección) Apt. # City Ciudad
Jump Start II Summer Program, 2017 June 26 - July 20 (no classes July 3rd or 4th)
Jump Start II Summer Program, 2017 June 26 - July 20 (no classes July 3rd or 4th) New this year *8:00-12:00 *no classes Fridays Questions? *Sunny Hill Summer School Of ce : 847-426-4232 *Dr. Armendariz-Maxwell,
OFFICE OF POLICY, PROCEDURES, AND TRAINING James K. Whelan, Executive Deputy Commissioner
OFFICE OF POLICY, PROCEDURES, AND TRAINING James K. Whelan, Executive Deputy Commissioner Stephen Fisher, Assistant Deputy Commissioner Office of Procedures POLICY BULLETIN #15-99-OPE ANNOUNCEMENT OF TWO
GUIDE TO THE REQUIREMENTS OF THE CALIFORNIA SCHOOL IMMUNIZATION LAW FOR Parents of Children In or Entering School or Child Care REFERENCE Health and Safety Code, Division 105, Part 2, Chapter 1, Sections
Who: 3rd - 5th Where: TBD
Who: 3rd - 5th Where: TBD Tuesdays, 3:15 p.m. - 4:15 p.m. Feb 5th - Apr 2nd Cost: FREE Club Organizer: Claudia Ortiz claudia.ortiz@austinisd.org We are capped at 16 students Registration forms due Jan
Township of Union Complaint Form. Note: The following information is needed to assist in processing your complaint.
Township of Union Complaint Form Note: The following information is needed to assist in processing your complaint. A. Complainant s information: Name: Address: City/State/Zip Code: Telephone Number (Home):
ORDEN FRATERNAL DE POLICÍA Sergeant D.P. Land Memorial Lodge # 82 Post Office Box 1374 Cumming, Georgia 30028
FOP Cops and Kids Sgt. D.P. Land Memorial Lodge #82 Of the Fraternal Order of Police Christmas Assistance Program ***Complete one application per family*** Please return the completed form to the place
Creating New Parent Accounts on SDUHSD Information Portal
Creating New Parent Accounts on SDUHSD Information Portal Open your internet browser. Type in the URL address my.sduhsd.net Click on CREATE NEW ACCOUNT located on the bottom. In order to create an account,
Applicant Last Name: First (Print clearly) Current Grade: (circle one):pre- K K September 2017 Grade
Application for Enrollment & Waitlist 2017-2018 Applicant Last Name: First (Print clearly) Current Grade: (circle one):pre- K K 1 2 3 4 5 September 2017 Grade Date of Birth Male[ ] Female[ ] School District
DOES YOUR CHILD HAVE ASTHMA? No STOP HERE Yes Please complete this form
DOES YOUR CHILD HAVE ASTHMA? No STOP HERE Yes Please complete this form If you have any questions, please contact your child s school nurse. Date form completed: Student ID Student Name: Birth date: Parent/Guardian
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
WINTER RECREATIONAL LEAGUE SESSION II
WINTER RECREATIONAL LEAGUE SESSION II REGISTRATION FORM 2018 PLAYER LAST NAME: PLAYER FIRST NAME: PLAYER BIRTHDAY: SHIRT SIZE: HOME PHONE: CELL PHONE: STREET: TOWN NJ ZIP CODE: EMAIL DAD S NAME MOM S NAME
PRINTING INSTRUCTIONS
PRINTING INSTRUCTIONS 1. Print the Petition form on 8½ X 11inch paper. 2. The second page (instructions for circulator) must be copied on the reverse side of the petition Instructions to print the PDF
Formulario de Postulación Universidad Católica Santo Toribio De Mogrovejo Estudiante de Intercambio Application Form / Exchange Student
Formulario de Postulación Universidad Católica Santo Toribio De Mogrovejo Estudiante de Intercambio Application Form / Exchange Student Información Personal Personal Information: Nombre FIrst Name Apellido
DOÑA ANA COUNTY HEAD START TOILET TRAINING PLAN LETTER TO PARENT
DOÑA ANA COUNTY HEAD START TOILET TRAINING PLAN LETTER TO PARENT : Child s Name: Center: Dear: Attached is a copy of the toilet training plan for your child which we will be using at the center. We are
EL PRIMER PASO, LTD. CHILD S ADMISSION RECORD * **REGISTRO DE ADMISION DE NIÑOS Nombre del niño (a) Fecha de matrícula
Class Preference Class Assigned Aftercare Program Tier Deposit Memo Staff initial EL PRIMER PASO, LTD. CHILD S ADMISSION RECORD 2013-2014 * **REGISTRO DE ADMISION DE NIÑOS 2013-2014 Nombre del niño (a)
CIRCUIT ORPHANS COURT FOR, MARYLAND City/County TRIBUNAL DE CIRCUITO TESTAMENTARIO PARA, MARYLAND Ciudad/Condado
CIRCUIT ORPHANS COURT FOR, MARYLAND City/County TRIBUNAL DE CIRCUITO TESTAMENTARIO PARA, MARYLAND Ciudad/Condado Located at Case No. Court Address Ubicado en Dirección del tribunal Número de caso In the
Welcome to the CU at School Savings Program!
Welcome to the CU at School Savings Program! Thank you for your interest in Yolo Federal Credit Union s CU at School savings program. This packet of information has everything you need to sign your child
Times: Retest Preparation tutorials are from 8:30-12:30, Monday Thursday, June
June 6, 2013 Dear Parent of: The Grand Prairie Independent School District is offering Retest Preparation for the State of Texas Academic Assessment of Readiness (STAAR) End of Course assessments in English
NOTICE OF CHALLENGE OF APPLICATION
Section 13.074, Texas Election Code BW1-5, 01/2015 NOTICE OF CHALLENGE OF APPLICATION Notice is hereby given that your application for voter registration has been challenged pursuant to Sec. 13.074 Texas
Formularios de FCC para los padres completear
1 Formularios de FCC para los padres completear www.communitychildcaresolutions.org 1 LISTA DE VERIFICACIÓN DEL NIÑO 2 Antes de la admisión de su hijo (a). Por favor complete los siguientes formularios.
Child s Full Name: School attending: Grade : Birthdate: Birthplace: Gender: M F
FAITH FORMATION REGISTRATION FORM 2016-2017 Family Name: Address: City: Zip Code: Home phone: Mom: Name: Maiden Name: Dad: Name: Cell: Cell: Email: Email: Children information Child s Full Name: School
INTERNATIONAL ADMISSIONS
INTERNATIONAL ADMISSIONS ADMISIONES INTERNACIONALES IMPORTANT: ENTIRE APPLICATION MUST BE COMPLETED. PLEASE READ CAREFULLY. IMPORTANTE: SE DEBE COMPLETAR TODA LA SOLICITUD. FAVOR DE LEER CON DETENIMIENTO.
Voter Information Guide and Sample Ballot
Voter Information Guide and Sample Ballot Special Election San Bernardino Mountains Community Hospital District Tuesday, June 4, 2013 Elections Office of the Registrar of Voters 777 East Rialto Ave. San
I, the. submits the. The Annual Guardianship Plan for the period beginning, El Informe anual de la tutela corresponde al periodo que se inicia el
IN THE CIRCUIT COURT FOR ORANGE COUNTY, FLORIDA PROBATE DIVISION / DIVISIÓN DE SUCESIONES IN RE: GUARDIAN ADVOCATE OF ASUNTO: CURADOR DE Case No /No. de causa: ANNUAL GUARDIAN ADVOCATE REPORT ANNUAL GUARDIAN
Back to S chool. Information Sheets (K-6) Ashley Sanderson Flying High in First Grade
Back to S chool Information Sheets (K-6) Ashley Sanderson Flying High in First Grade Welcome Pre-K Parents Please help me get to know your child by filling out the following form! Thank you! Child s name:
Carta de Preocupaciones y sugerencias de los padres. (Nombre del niño/a)
Carta de Preocupaciones y sugerencias de los padres Documento #1 Carta de Preocupaciones y sugerencias de los padres para: (Nombre del niño/a) Fecha: Equipo del IEP, Yo/Nosotros esperamos trabajar en colaboración
Hearing Loss. Causes. Signs
Hearing Loss Hearing loss is a sudden or gradual decrease in being able to hear. There are different types of hearing loss: Conductive Hearing Loss: Sound is blocked. This is often caused by earwax build
Opp Elementary School APPLICATION FOR STUDENT ENROLLMENT PLEASE PRINT Must be completed by Parent/Legal Guardian SCHOOL YEAR:
Opp Elementary School APPLICATION FOR STUDENT ENROLLMENT PLEASE PRINT Must be completed by Parent/Legal Guardian SCHOOL YEAR: 2017-18 DATE: _ SCHOOL: OPP ELEMENTARY SCHOOL GRADE: FIRST NAME: MIDDLE NAME:
As the 2013-14 school year comes to a close, Camden City School District is excited to get summer programming underway!
June 2014 Dear Parents and Guardians: As the 2013-14 school year comes to a close, Camden City School District is excited to get summer programming underway! The District Summer School Program will operate
Como crear una cuenta para registrar a su hijo/a en programas de recreación
Como crear una cuenta para registrar a su hijo/a en programas de recreación 1. Entre a nuestra pagina de web csh.recdesk.com 2. Oprime Log In 3. Oprime Create New Account 4. Entre el nombre de su hijo/a
Favor de cortar y mantenga esta página junto con nuestra información de contacto que aparece abajo. Gracias!
Please tear off and keep this page with our contact information below. Thank you! DEPARTMENT OF JUSTICE CRIME VICTIMS SERVICES DIVISION APPLICATION FOR CRIME VICTIM COMPENSATION You may qualify for help
Vermont Focus Lesson. Filling Out A Form
Vermont Focus Lesson Filling Out A Form Regular Sample Form Date: First Name: Last Name: Street Address: City: State: Zip Code: Phone Number: Amount: Fecha: September 12, 2011 Sample Information mbre:
/ INSCRIPCIÓN / / REGISTRATION S /
c a m p u s d e v e r a n o v a l e n c i a 1 c a m p u s d e v e r a n o v a l e n c i a / INSCRIPCIÓN / / REGISTRATION S / / CAMPUS DE VERANO 2017 / / SUMMER CAMP 2017 / c a m p u s d e v e r a n o v
SECTION SD. HEALTH SERVICES
SECTION SD. HEALTH SERVICES Note: Only Next-of-Kin Interviews (n=1,209). Some questions may have missing values if the section was not completed. Only n=7 observations were included in the final data sets