Thank you for your interest  in Brentwood Borough School District.  The following is a list of the documentation you will need to provide  at the time of your registration. The attached checklist and completion of the attached documents  will help to make your registration as quick and easy as possible. Please allow a minimum of 3 school days from the date all records have been submitted for your child's registration to be completely processed.

Please make an appointment to register your child after you have gathered all needed paperwork and completed the attached  forms.  Appointments can be scheduled by contacting Dr. Chris Winiarski at
412-881-4940 ext 2215.

REGISTRATION CHECKLIST

Please bring the following to your appointment:

1. 	Child's birth  certificate/ court order listing you as custodial parent/guardian
2. 		Current lease agreement, original deed to your home, or current mortgage statement listing your address
3.   Two (2) current  documents  demonstrating your residence in the borough.  Acceptable
documentation for proof  of residency may include:
 	current  utility bill (gas, electric, water, cable, telephone)  in your name at the address of your residence  within the district.
 	IRS statement  or other wage and tax statements, e.g., W2, 1040, 1099
 	Voter Registration Card showing current  address
 	Recent employer  pay stub showing current  address
Recent letter  from  a government agency with the parent/guardian's name and current address (i.e., Social Security, Public Assistance, IRS, etc.)
Current PA driver's license/Non-driver's license with your current  address
 	Current vehicle registration or car insurance policy with your current  address
 	Current credit card bill with your current  address
 	Recent bank statement with your current address
4. 	Your child's immunization record
5.   Any legal documents  concerning your child- Custody Orders, PFAs, etc. Please complete and bring these forms from  the enrollment packet:
1.    Residency Verification Form
2. 	Parental Registration Statement
3. 	Enrollment Record
4.   Authorization for Release of Educational Records
5. 	Home Language Survey
6.   AIU English as a Second Language Student Background Questionnaire (if applicable- Only complete  if English is NOT the student's  native language)
7.   Student Residency Questionnaire
8. 	Family Access Registration
9. 	Health History and Certification of Immunization Status
10. Private or School Physical Examination of School Age Student

BRENTWOOD BOROUGH SCHOOL DISTRICT RESIDENCY VERIFICATION

Parent/Guardian/Foster  Parent 	 Home Telephone Number Address 	 Work Telephone Number Student Name 	Grade 	Age Student Name 	Grade 	Age Student Name 	Grade 	Age
Section 1  Please read and  answer all questions that apply.	

1.  Are you the child's  custodial parent or guardian? 	DYes	DNo
If yes- present copy of birth certificate and/or court order and go to
question #4
If no - go to question #2	

2.   Are you a foster parent to the child? 	DYes	DNo
If yes- complete questions 3 through 5
If no -complete Parents' Declaration and Authorization for Admission of Non-resident Student, then complete questions 4 and 5	

3.   As a foster parent, are you receiving any form of compensation to support 	DYes	DNo this child?	

4.   Are you currently a resident of the Brentwood Borough School District? 	DYes	DNo
If yes- proceed to question #5
If no- go to Section 2 on the back of this form	

5.   At this time, you must present documentation in your name demonstrating that your residence is
within the Brentwood Borough School District.  The District requires you to present a current, original lease agreement, the original deed to your home or a current, original tax statement in your name at the address of your residence along with any two (2) of the following forms of documentation:

a.   A valid Pennsylvania Driver's  License or Pennsylvania ID Card with the address listed above. b.   Proof of utilities in your name at the address listed above.  These include gas, electric, sewage,
water, or telephone.
c.    A valid U.S. Passport with your name at the address listed above.
d.   A payroll check or government check stub with your name at the address listed above. e.   An IRS tax return within the last year with your name at the address listed above.	

Section 2  Eligibility of Non-resident Students

I.   Has the parent/guardian executed a contract to buy or rent a residence in the 	0 Yes 	DNo
District?
If yes- the parent/guardian must complete a Future Resident Certification
Form
If no -you are not eligible to enroll your student(s) in the Brentwood Borough
School District.

Within thirty (30) days of completion of the contract, the parent/guardian must show a current, original lease agreement or the original deed to the home in the parent/guardian's  name at the address of residence along with any two (2) of the following forms of documentation:

a.   A valid Pennsylvania Driver's License or Pennsylvania ID Card with the address of your residence.
b.   Proof of utilities in your name at the address of your residence.  These include gas, electric, sewage, water, or telephone.
c. 	A valid U.S. Passport with your name at the address of your residence.
d.   A payroll check or government check stub with your name at the address of your residence. e. 	An IRS tax return within the last year with your name at the address of your residence.

The  District reserves the right to verify  all claims.

Date of Residency Verification  	_

Signature of Parent/Guardian

I have  reviewed all information needed  and  found  that this student may enroll  in the Brentwood
Borough School District.

Signature of Building Principal

Administrative Offices
3601 Brownsville Road
Pittsburgh, PA 15227-3117
Phone:	412-881-2227
Fax:	412-881-1640

Brentwood High School
3601 Brownsville Road
Pittsburgh. PA 15227-3117
Phone:	412-881-4940
Fax: 	412-881-4170

Guidance Office
3601 Brownsville Road
Pittsburgh. PA 15227-3117
Phone:	412-881-4940 x2131
Fax:	412-881-4170

Brentwood Middle School
3601 Brownsville Road
Pittsburgh. PA 15227-3117
Phone:	412-881-4940
Fax: 	412-881-4170

Special Education Office
3601 Brownsville Road
Pittsburgh. PA 15227-3117
Phone:	412-881-4940 x2215
Fax:	412-881-7195

Elroy Elementarv School
3129 Elroy Avenue
Pittsburgh, PA 15227-2824

SCHOOL DISTRICT OF THE BOROUGH OF BRENTWOOD

Parental Registration Statement

Student Name	 		

Date of Birth	

Parent/Guardian Name	

Address		

Telephone Number	

Pennsylvania School Code 13-1304-A states in part "Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration, provide a sworn statement or affirmation stating whether the pupil was previously suspended or expelled from any public or private school of this Commonwealth or any other state for an act of offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property."

Please complete the following:

I hereby swear or affirm that my child was  	I was not  	previously suspended or expelled from any public or private school of this Commonwealth or any other state for any act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed  on school property.* I make this statement subject to the penalties of 24 P.S. Section 13-1304-A(b) and 18 Pa C.S.A. Section
4904, relating to unsworn falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge, information and belief.

Phone:	412-881-4484	 	

Fax: 	412-881-9448

Moore Elementarv School
3809 Dalewood Street
Pittsburgh, PA 15227-3509
Phone:	412-881-7776
Fax: 	412-881-8994

Athletic/Activity Director
3601 Brownsville Road
Pittsburgh, PA 15227-3117
Phone 	412-881-4940 x2720
Fax:	412-881-1640

(Signature of Parent/Guardian)

(Date)

*Name of the school from which student was suspended or expelled; reason for suspension/expulsion; and dates of suspension or expulsion (optional)

Any willful false statement made above shall be a misdemeanor of the third degree. This form shall be maintained as part of the student's disciplinary record.

www.bb-sd.com

Brentwood Borough  School District

Today's date:	Registering for Grade:	
STUDENT INFORMATION	
Student's last name: 	First: 	Middle:	
Birth  place:  (city/state/country)	Birth date: 	!	Age:	ex:
OM 	OF	
Home address:	Primary phone:
home 	cell 	work
(	)	2nd phone:
home 	cell 	work
(	)	
City:	State:	IP Code:	
Birth  certificate?	/oP Yes	Custody order?   /P Yes	/If yes, order provided?	/oP Yes	
What is your ethnicity?
o Hispanic  or Latino
o Not Hispanic  or Latino	What is your race?
o American Indian or Alaska Native
o Asian
o Black or African American
o Native Hawaiian or Other Pacific Islander
o White	
Student  lives with: (Please check all that apply and print  information)	
o Father	Email:	
Father's  address	Phone:	
o Mother	Email:	
Mother's address	Phone:	
o Stepfather	Phone:	
o Stepmother	Phone:	
o Legal guardian(s)	Email:	
Legal guardian's address	Phone:	
o Foster parent(s)	Email:	
Foster parent's address	Phone:	
BROTHERS I SISTERS	AGE	SCHOOL	

			

			
			
Does your child  receive special education services?	o Yes
o No	If yes, type of program:
o IEP o Gifted  o Chapter 15/504 Plan  0 Speech IEP	

ENROLLMENT  RECORD

No 	o No 	No

PAGE2

BRENTWOOD  BOROUGH SCHOOL DISTRICT ENROLLMENT  RECORD

FORMER SCHOOL	
Name of former school:	Grade:	
School district:	County:	State:	
Name of former school:	Grade:	
School district:	County:	State:	
Name of former school:	Grade:	
School district:	County:	State:	
Has student previously	DYes attended Brentwood schools? 	 D No	If yes, what:
Year:	Grade: 	School:	
Has your child  repeated any grade? 		Yes	llf yes, please list the grade: D No	

Signature of person completing this form:-------------------------- Relationship to child:--------------	Date:  	_

10/17

:, : '	( i  '

Administrative Offices
3601 Brownsville Road
Pittsburgh, PA 15227-3117
Phone: 	412-881-2227
Fax	412-881-1640

Brentwood High School

SCHOOL DISTRICT OF THE BOROUGH OF BRENTWOOD Authorization for Release of Educational Records
Date:

Student Name:
I hereby authorize the release of records from the agency/person(s) listed below: From:	To:

3601 Brownsville Road
Pittsburgh, PA 15227-3117
Phone: 	412-881-4940
Fax: 	412-881-4170

Guidance Office
3601 Brownsville Road
Pittsburgh, PA 15227-3117
Phone: 	412-881-4940 x2131
Fax: 	412-881-4170

Former Agency or School Name

Street Address

City, State, Zip

Phone#:

D Elroy Elementary School

D Moore Elementary School D Brentwood Middle School D Brentwood High School

Brentwood Middle School
3601 Brownsville Road
Pittsburgh, PA 15227-3117
Phone:	412-881-4940
Fax: 	412-881-4170

Special Education Office
3601 Brownsville Road
Pittsburgh, PA 15227-3117
Phone: 	412-881-4940 x2215
Fax	412-881-7195

Elroy Elementary School
3129 Elroy Avenue
Pittsburgh, PA 15227-2824
Phone:	412-881-4484
Fax:	412-881-9448

Moore Elementary School
3809 Dalewood Street
Pittsburgh, PA 15227-3509
Phone	412-881-7776
Fax: 	412-881-8994

Athletic/Activity Director
3601 Brownsville Road
Pittsburgh. PA 15227-3117
Phone: 	412-881-4940 x2720
Fax: 	412-881-1640

Fax#:    	

Check all record types to be released:
[8J Health Records	[8J Attendance  Records	[8J Verbal/Written Communications

[8J Special Education Records (Evaluatien-Reports,-lmliviElualized- duGation-ProgFam)­

[gl Transcripts, Report Cards and Standardized Test Results

[8J All other relevant information pertaining to education planning

The reason for disclosing the records is for referral, assessment and to facilitate educational planning.

I understand that the information obtained will be treated in a confidential manner and will not be transmitted to a third party without my permission. It is my right to request a copy of all information and contest  anything  that I feel is incorrect.

Parent/Guardian Signature Street Address, City, State, Zip Contact Phone #
http://bb-sd.corn

Brentwood Borough  School District
Home Language  Survey*

The  Office of Civil Rights  (OCR) requires  that school districts/charter schools/ full day AVTS identify limited  English  proficient  (LEP) students in order  to provide appropriate language instructional programs for them.   Pennsylvania has selected  the Home Language Survey  as the method for their identification.

School: 	D Elroy 	D Moore

Student Name:

1.   What is/was the student's first language? -----------------

2.    Does the student speak a language other  than  English?    D Yes

0No

If yes, please specify the language:   	

.'3.     What language is spoken in your home? -------------------

4.    Has the student attended  a school in the United  States  in the last .'3  years?

DYes	0No

If yes, please complete  the following:

Narne of School 	State 	Dates  Attended

Person  completing this form (if other  than the Parent/Guardian):

Parent/Guardian Signature: -----------------------------

*The school district/charter school/full day A VTS has the responsibility under the federal law to serve students who are limited  English  proficient and need English  instructional  services.  Given this responsibility, the school district/charter school/fitll  day AVTS has the right  to ask for the information  it needs to identify English  Language  Learners  (ELLs).  As part of the responsibility  to locate and identi(y ELLs, the school district/ charter school/fiJll day A VTS may conduct screenings or ask for related information  about students who are already enrolled  in the school as well as fi·mn students who enroll  in the school district/charter school/full day AVTS in the future.

Revised I /22/ H

Please file original with student's records.
Forward a copy to your District ESL Administrator.

PA Secure ID:   	  School District:   	
School:   	Grade:

English as a Second Language
Student Background  Questionnaire

Student's Name: -------.,.,..-----------,--.,.------------ (First)	(Last)

Male I Female circle one

Birthday: -------­ (month) (day)  (year)

Age:  	Telephone:   	_

Address: ------------------------------------------ Father's Name -------------- Father's Native Country ---------
Mother's Name --------------- Mother's Native Country ------- Names and ages of brothers and sisters: -----------------------

Names and relationships of others living in the home: -------------------

Was your child born outside the U.S?	D No 	D Yes	If yes, list the country:   	_ Child's First Spoken Language:  ---------------------------
When did this student come to the United States?  ------------------- What language is used with parents?  --------	With siblings? --------
With friends?  ---------

If your child is cared for by another person, what language is most often used?  --------- Is an interpreter needed for home/school communication? 	D  No 	DYes

My child...	Very well	Only a little	Not at all	
				
Reads English				
Writes English				
Reads first language				
Writes first language				

Student's Name:   -------------------------------

SCHOOL HISTORY

Please give the following information.   Fill in name of each school one time.   Indicate any breaks in schooling.  Give any information that would help us understand your student's background better.

Age	Grade	Name of School; Location 	Language( s) Used	
4			
5			
6			
7			
8			
9			
10			
11			
12			
13			
14			
15			
16			
17			
18+			

Last grade completed:   	_

Has your child studied English?

When?  -----------
D  No	D  Yes	How long?  	

Has your child ever received ESL instruction?	D  No 	D  Yes	Where?---------- Additional information you want us to know:
Student's special interests: ------------------------------­ In school, student does well in: ---------------------------------­
Special medical problems the school should know about:

Does your child have learning difficulties? ----------------------------­ Other:   	

Form filled out by:   	
(Signature)	(Date)

Student grade placement (if determined):   	

C:cUsers·.nirod/-.ppD.?.lOJ\Loca!<tv icros f!\VV!:ldows\Ternpnrarylnternat Fdes\ContenLOuUook\YOHPA.75!\.,1\Quest:onna:re- Re•;!sed August 2009- Districts.doc

Dear Parent or Guardian,

School District
Student Residency Questionnaire

Your responses to these questions will help staff determine what residency documents  are necessary to enroll your child.  Thank you for your cooperation.

1.   Student name: 	Birth date:

Person completing form: -------------------------- Relationship to child:   	
2.   In what type of setting is the child living now? Check one box below:

Section A	Section B	

D In an emergency or transitional shelter

D Sharing the housing of other persons due to loss of housing, economic hardship, or similar reason

D In a motel, hotel, campsite, or car due to a lack of alternative, adequate accommodations

D In a car, park, public space, abandoned  building, substandard housing, bus or train stations, or similar settings

D Other places not designed for, or ordinarily used as, regular sleeping accommodations for human beings

CONTINUE TO THE QUESTIONS BElOW if you checked a box in SECTION A	
D None of the choices in
SECTION A apply

If you checked this section, you do not need to complete questions 3 through 6.  Please sign and date the form  and turn  it in.	

3.  Contact number  for person completing this form: Address where the child is now living:
4.  The child lives with  (Check all that apply):

D Parent or legal guardian
D Relative, friend or other adult
D Alone
D Other:

5.   Name, Address & Phone Number ofthe school the child attended last:	 	

6.   Does the child have an IEP or a Chapter 15/504 agreement?
D No.
D Yes. Please explain:  --------------------------------------------------------------

Signature of Pare nt/LegaI Guardian:-------------------------------------	Date: ---------------

Brentwood  Borough School District
Family Access Registration

Please fill in the appropriate information below for each parent and/or guardian that would like to have a login and password to access your childns school information using Family Access. If parents and/or guardians would like to share one login, please fill in only one guardian name and e-mail address. If you would like multiple parents and/or guardians to have their own access, please fill in both guardian names and e-mail address fields.
This is a free service.

Please print legibly (illegible forms will not be processed).
Guardian Full Name:--------------------------- Phone#--...,--------,----	*Email-----------------
*An email address is required to receive your confidential user name and password.

Guardian Full Name:--------------------------- Phone#  	_	Email  	_

Please list below the names of your children, the school they attend and their relationship to you.

Student Name 	School 	Relationship

Please select one option below:

Send my password(s) via email

No password is requested± I waive this service

Signature------------------	Date 	_

FOR OFFICE USE ONLY

Date Request Received: ----------------- Date Completed:  	_ 	By:  	_

Brentwood Elementary Schools

Health  History and Certification of Immunization Status

Student Name:

Home Address:

Phone  Number:  -------------------------------
Father's  Name: Mother's  Name:
Person  with whom the student lives:

Birth Date:

D Female

D  Male

VACCINES RECEIVED

(You may attach  a printed  copy from your doctor's office or fill in the dates  below.)

Any combination of
DTP, DT  and TD

4
(Last  one must  he after 'i·'h b'

OPV (Oral  Polio) 	3

MMR  (Measles, 	2
Mumps,  Rubella)

Hepatitis B	3

Varicella  (Or date 	2
that  your  child had

The  Commonwealth of Pennsylvania requires  physical examinations for students in Kindergarten (or upon
entrance to school), 61h, and  11th grades.   Dental  examinations are required  in grades  1, 3 and 7.

I prefer  that  my child be examined  by:   D  My personal  physician

I prefer  that  my child be examined  by:   D  My personal  dentist

D The  school physician

D  The  school dentist

Has your child had and of the following (Please provide details):

Ear problems:-------------------------------------------------------------------------

Vision/Eye problems:

-------------------------------------------------------------------

PLEASE  COMPLETE THE BACK OF THIS FORM 	c====>

Hospitalization:

Chronic  or recurrent illness or condition:  ------------------------------------------------------

Operations:

------------------------------------------------------------------------------

Emotional problems: Seizures:
Asthma:

Allergies:

--------------------------------------------------------------------------------

Please list any other  health concerns that you feel are important for the school to be aware of:

Please list  below any medications  that your child takes on a regular  basis.  Please  note whether  it will be necessary for your child to receive these medications  while they are at school.

Would  you like a conference  with  the school nurse?   D Yes 	D No
Can the medical information on this form be shared  with the school staff? 	D Yes 	0No

H511.336 (Rev. 9/2012) 	Page 1 of 4: STUDENT HISTORY

pennsylvania
DEPARTMENT OF HEALTH

Bureau  of Community Health Systems
Division of School  Health

Private or School PHYSICAL EXAMINATION OFSCHOOLAGESTUDENT

PARENT I GUARDIAN I STUDENT:
Complete page one of this form before student's exam. Take completed form to appointment.

Student's name--------------------------------	Today's date  	_

Date of birth  	_

Age  at time  of exam 	_

Gender: D Male     D Female

Medicines and Allergies: Please list  all prescription and  over-the-counter medicines and  supplements (herbal/nutritional) the student is currently taking:

Does the student have  any  allergies? D No    D Yes (If yes, list specific allergy and  reaction.)

D Medicines

D Pollens

D Food

D Stinging Insects

Complete the following section with a check mark in the YES or NO column; circle questions you do not know the answer to.

GENERAL HEALTH:    Has the student...	YES	NO	
1. Any ongoing medical conditions?  If so, please identify: D Asthma    DAnemia  D Diabetes    D Infection
Other			
2. Ever stayed more than one night in the hospital?			
3. Ever had surgery?			
4. Ever had a seizure?			
5. Had a history of being born without or is missing a kidney, an eye, a testicle (males), spleen, or any other organ?			
6. Ever become ill while exercising in the heat?			
7. Had frequent muscle cramps when exercising?			
HEAD/NECK/SPINE:    Has the student...	YES	NO	
8. Had headaches with exercise?			
9. Ever had a head injury or concussion?			
10 Ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?			
11. Ever had numbness, tingling, or weakness in his/her arms or legs after being hit or falling?			
12 Ever been unable to move arms or legs after being hit or falling?			
13 Noticed or been told he/she has a curved spine or scoliosis?			
14 Had any problem with his/her eyes (vision) or had a history of an eye injury?			
15 Been prescribed glasses or contact lenses?			
HEART/LUNGS: 	Has the student...	YES	NO	
16 Ever used an inhaler or taken asthma medicine?			
17 Ever had the doctor say he/she has a heart problem?  If so, check all that apply: 	D Heart murmur or heart infection
D High blood pressure 	D Kawasaki disease
D High cholesterol 	D Other:			
18. Been told by the doctor to have a heart test? (For example, ECG/EKG, echocardiogram)?			
19. Had a cough, wheeze, difficulty breathing, shortness of breath or feltlightheaded  DURING or AFTER exercise?			
a! Had discomfort, pain, tightness or chest pressure during exercise?			
21. Felt his/her heart race or skip beats during exercise?			
BONE/JOINT: 	Has the student...	YES	NO	
22 Had a broken or fractured bone, stress fracture, or dislocated joint?			
23 Had an injury to a muscle, ligament, or tendon?			
24. Had an injury that required a brace, cast, crutches, or orthotics?			
25 Needed an x-ray, MRI, CT scan, injection, or physical therapy following an injury?			
a5. Had joints that become painful, swollen, feel warm, or look red?			
SKIN: 	Has the student...	YES	NO	
27. Had any rashes, pressure sores, or other skin problems?			
28. Ever had herpes or a MRSA skin infection?			

GENITOURINARY: 	Has the student... 	YES	NO
29. Had groin pain or a painful bulge or hernia in the groin area?
30. Had a history of urinary tract infections or bedwetting?
31. FEMALES ONLY: Had a menstrual period? 	DYes 	D No
If yes: At what age was her first menstrual period?   	
How many periods has she had in the last12  months?  	 Date of last period:
DENTAL: 	YES	NO
32 Has the student had any pain or problems with his/her gums or teeth?
33. Name of student's dentist:  	
Last dental visit: D less than 1 year    D 1-2 years    D greater than 2 years
SOCIAULEARNING:    Has the student•.. 	YES 	NO
34. Been told he/she has a learning disability, intellectual or developmental disability, cognitive delay, ADD/ADHD, etc.?
35. Been bullied or experienced bullying behavior?
36. Experienced major grief, trauma, or other significant life event?
37. Exhibited significant changes in behavior, social relationships, grades, eating or sleeping habits; withdrawn from family or friends?
38. Been worried, sad, upset, or angry much of the time?
39. Shown a general loss of energy, motivation, interest or enthusiasm?
40. Had concerns about weight; been trying to gain or lose weight or received a recommendation to gain or lose weight?
41. Used (or currently uses) tobacco, alcohol, or drugs?
FAMILY HEALTH: 	YES 	NO
42. Is there a family history of the following?  If so, check all that apply: D Anemia/blood disorders 	D Inherited disease/syndrome D Asthma/lung problems 	D Kidney problems
D Behavioral health issue 	D Seizure disorder
D Diabetes	D Sickle cell trait or disease
  Other 	
43. Is there a family history of any of the following heart-related problems?  If so, check all that apply:
D Brugada syndrome 	D QT syndrome
D Cardiomyopathy 	D Marfan syndrome
D High blood pressure 	D Ventricular tachycardia
D High cholesterol 	D Other
44. Has any family member had unexplained fainting, unexplained seizures, or experienced a near drowning?
45. Has any family member I relative died of heart problems before age
50 or had an unexpected I unexplained sudden death before age
50 (includes drowning, unexplained car accidents, sudden infant death syndrome)?
QUESTIONS oR CONCERNS 	YES 	NO
46.  Are there any questions or concerns that the student, parent or guardian would like to discuss with the health care provider?   (If yes, write them on page 4 of this form.)

I hereby certify that to the best of my knowledge all of the information is true and complete. I give my consent for an exchange of health information between the school nurse and health care providers.

Signature  of parent I guardian I emancipated  student 	Date. 	_

Adapted in part from the Pre-participation Physical  Evaluation History Form; ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of
Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

Page 2 of 4: PHYSICAL EXAM

STUDENT'S HEALTH HISTORY (page 1 of this form) REVIEWED PRIOR TO PERFOMING EXAMINATION: Yes  0 	NoD	

Physical exam for grade:

K/10 60  11 0  Other 0	
CHECK ONE	

*ABNORMAL FINDINGS I RECOMMENDATIONS I REFERRALS	

...J
c(
::0
0::
0
z	
...J
c(
::0
0::
0z
m	

0:: w u.. w
0		

Height: 	( 	) inches					

Weight:    ( 	) pounds					
BMI: 	( 	1					
BMI-for-Age Percentile: (	)%					

Pulse: 	( 	)					

Blood Pressure:   ( 	I 	)					

Hair/Scalp					
Skin					

EyesNision 	Corrected  0					

Ears/Hearing					

Nose and Throat					

Teeth and Gingiva					
Lymph Glands					
Heart					

Lungs					

Abdomen					

Genitourinary					
Neuromuscular System					

Extremities					

S_Qine_(Scoliosis)					
Other					

TUBERCULIN TEST	DATE APPLIED	DATE READ	RESULT/FOLLOW-UP	

MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION,RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION

(Additional space on page 4)

Parent/guardian present during  exam:  Yes  0	No 0

Physical exam performed  at:  Personal Health Care Provider's Office   0	School 0	Date of exam, 	20 	_

Print  name of examiner  	_

Print examiner's office address. 	Phone 	_

Signature of examiner  	MOD

DOD	PAC D

CRNP D

Page 3 of 4: IMMUNIZATION HISTORY

HEALTH CARE PROVIDERS: Please photocopy immunization history from student's record- OR- insert information below.

IMMUNIZATION EXEMPTION(S):

Medical D	Date Issued: 	

Reason: ---------------------

Date Rescinded: 	_

Medical D 	Date Issued:	Reason: --------------------- Medical D 	Date Issued:	Reason: ---------------------

Date Rescinded: 	_

Date Rescinded: 	_

NOTE: The parent/guardian must  provide a written  request to the school for a religious or philosophical exemption.

VACCINE 	DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization
L	, 	,
Diphtheriaffetanus/Pertussis  (child) Type: DTaP, DTP or DT
, 	,
Diphtheriaffetanus/Pertussis 	L
(adolescenVadult)

Type: Tdap or Td

Polio
Type: OPV or IPV

<	0	.	5

,

L
Hepatitis B (HepB)

L

, 	,
Measles/Mumps/Rubella (MMR)

Mumps disease diagnosed by physician  D 	Date:

<	0 	.

5
Varicella:  Vaccine D 	DiseaseD

£	J
Serology: (Identify Antigen/Date/POS or NEG)
i.e. Hep B, Measles, Rubella, Varicella
, 	,
L

,

Meningococcal Conjugate Vaccine (MCV4)

£	0
Human Papilloma Virus (HPV)

Type: HPV2 or HPV4

£ 	0	.	0

Influenza	0	.	,	10
Type: TIV (injected)

LAIV (nasal)

Haemophilus lnfluenzae Type b (Hib) Pneumococcal Conjugate Vaccine (PCV)
Type:7or13

>£ 	,, 	,,

,

L

,

L

£	0 	.

5

,

Hepatitis A (HepA)

L
Rotavirus

Other Vaccines: (Type and Date)

Page 4 of 4:  ADDITIONAL COMMENTS (PARENT I GUARDIAN I STUDENT I HEALTH CARE PROVIDER)