MASSACHUSETTS SCHOOL HEALTH RECORD Health Care Provider’s Examination Name ________________________________________
Male
Female
Date of Birth:___________________
Medical History _________________________________________________________________________________________ _______________________________________________________________________________________________________ Pertinent Family History Current Health Issues Y N Allergies: Please list: Medications ______________________ Food _________________ Other ______________ History of Anaphylaxis to ___________________ Epi-Pen®: Yes No Asthma: Asthma Action Plan Yes No (Please attach) Diabetes: Type I Type II Seizure disorder: ____________________________________________________________________________ Other (Please specify) _________________________________________________________________________ Current Medications (if relevant to the student's health and safety) Please circle those administered in school; a separate medication order form is needed for each medication administered in school. Physical Examination Date of Examination:___________________________ Hgt: ________(_____%) Wgt:_________(_____%) BMI: _________(_____%) BP: ________ (Check = Normal / If abnormal, please describe.) General ________________ Lungs __________________ Extremities _____________ Skin __________________ Heart ___________________ Neurologic _____________ HEENT _______________ Abdomen _______________ Other __________________ Dental/Oral ____________ Genitalia ________________ Screening: (Pass) (Fail) Vision: Right Eye Left Eye Stereopsis Laboratory Results:
(Pass) (Fail)
Hearing: Right Ear Left Ear
Lead _______ Date _______________
(Pass) (Fail)
Postural Screening: (Scoliosis/Kyphosis/Lordosis) Other____________________________________
The entire examination was normal: Targeted TB Skin Testing: Med-to-High risk (exposure to TB; born, lived, travel to TB endemic countries; medical risk factors): Date of PPD: ____; Results: ____mm. Referred for evaluation to: _______________________________________ Low risk (no PPD done) This student has the following problems that may impact his/her educational experience: Vision Hearing Speech/Language Fine/Gross Motor Deficit Emotional/Social Behavior Other Comments/Recommendations:_____________________________________________________________________ Y N This student may participate fully in the school program, including physical education and competitive sports. If no, please list restrictions:_____________________________________________________________________________________ Y N Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information System Certificate or other complete immunization record. ______________________________________________ Signature of Examiner Circle: MD, DO, NP, PA Date
___________________________________________ Please print name of Examiner.
______________________________________________ Group Practice Telephone ___________________________________________________________________________________________________________ Address City State Zip Code Please attach additional information as needed for the health and safety of the student.
MDPH 03/19/15
CERTIFICATE OF IMMUNIZATION Name:
Date of Birth:
/
/
Sex:
M
F
Please indicate vaccine type (e.g., DTaP-Hib, etc.) Vaccine
Date
Hepatitis B
Vaccine Type
Date
Rotavirus
1
(e.g., HepB, HepB-Hib, DTaP-HepB-IPV, HepA-HepB)
Vaccine (e.g., RV5: 3-dose series, RV1: 2-dose series)
2 3 1
(e.g., DTP, DTaP, DT, DTaP-Hib, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV, Td, Tdap)
3
2
Varicella
1 2
5
Conjugate (MCV4) or Polysaccharide (MPSV4)
6
Seasonal Influenza Inactivated (Intramuscular) or Live (Intranasal)
1
3
H1N1 Influenza
1
4
Inactivated (Intramuscular) or Live (Intranasal)
2
Pneumococcal Polysaccharide
3
(PPSV23)
2 1
Human Papillomavirus
5 1
1
Hepatitis A (e.g., HepA, HepA-HepB)
4
(e.g., PCV7, PCV13)
1
3
2
Pneumococcal Conjugate
2
4
1
(e.g., IPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV)
1
2
2
Polio
1 2
Meningococcal
7
(e.g., Hib, HepB-Hib, DTaP-Hib, DTaPIPV/Hib)
2
(e.g., MMR, MMRV) (e.g., Var, MMRV)
4
Haemophilus influenzae type b
1 3
Measles, Mumps, Rubella
4 Diphtheria, Tetanus, Pertussis
Vaccine Type
2 1
(e.g., HPV quadrivalent,
2
2
HPV bivalent,)
3
3
Other:
4 Serologic Proof of Immunity Test (if done)
Date of Test
Check One Positive
Negative
Chickenpox History Check the box if this person has a physician-certified reliable
Measles
/
/
Mumps
/
/
Reliable history may be based on:
Rubella
/
/
• physician interpretation of parent/guardian description of chickenpox
Varicella*
/
/
• physical diagnosis of chickenpox, or
/
/
• serologic proof of immunity
Hepatitis B
history of chickenpox.
* Must also check Chickenpox History box.
I certify that this immunization information was transferred from the above-named individual’s medical records.
Doctor or nurse’s name (please print):
Date:
/
/
Signature: Facility name: Certificate of Immunization
Massachusetts Department of Public Health 4-10
ATHOL-ROYALSTON SCHOOL DISTRICT • KINDERGARTEN REGISTRATION FORM STUDENT NAME_____________________________________________________________________________________________ Male____ Female____ • Date of Birth: Month________ Day_________ Year__________
Place of Birth_____________________________________________________________ Country of Origin_____________________ Address____________________________________________________________________________________________________ Phone_______________________________Cell Phone____________________________Email______________________________ Any custodial legality (Restraining orders, custody orders, etc) the school should be aware of?
Yes____No____ Please submit copies of legal documents to school.
Any DCF Involvement? Yes____No____DCF Worker__________________________________Phone:_________________________
With whom does the student live? (circle all that apply)
Both Parents • Mom • Dad • Step Mom • Step Dad • Legal Guardian • Grandparent • Foster Parent • Other_____ Parent/Guardian #1 • Name_____________________________________________________________________________________ Address:___________________________________________________________________Phone:____________________________
Employer:__________________________________________________________________Phone:____________________________
Cell Phone:_________________________________________ Parent/Guardian #2 • Name_____________________________________________________________________________________ Address:___________________________________________________________________Phone:____________________________
Employer:__________________________________________________________________Phone:____________________________
Cell Phone:_________________________________________ 1. Does your child’s allergies or health condition constitute an emergency that warrants immediate attention? Yes____No____ 2. Will your child receive medication during the school day?
Yes____No____
If yes to either question one or two,, please see the school nurse. Physician name: _________________Phone___________________
3.List health problems and/or allergies_____________________________________________________________________________ ____________________________________________________________________________________________________________ 4. 3. Does your child wear glasses? Yes____No____
Please check any services your child receives:
IEP________504________Speech_______DCF________English Language Learner Services________
Has your child attended a Preschool or Child Care? Yes____No____
If yes, for how long? 6 months _____ 1 year _____ 2 years ______ more than 2 years ______ Name of your child’s present or most recent school:_______________________________________________________________ List names/schools of brothers and/or sisters:_______________________________________________________________________
___________________________________________________________________________________________________________
Parent Signature _________________________________________________________________ Date________________________
320151146
Athol-Royalston Regional School District Home Language Survey Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance.
Student Information First Name
Middle Name
Country of Birth
/ / Date of Birth (mm/dd/yyyy)
F Gender
Last Name
M
/ / Date first enrolled in ANY U.S. school (mm/dd/yyyy)
School Information / /20 ______ Start Date in New School (mm/dd/yyyy)
Name of Former School and Town
Current Grade
Questions for Parents/Guardians What is the native language(s) of each parent/guardian? (circle one)
Which language(s) are spoken with your child? (include relatives -grandparents, uncles, aunts,etc. - and caregivers)
(mother / father / guardian)
seldom / sometimes / often / always
(mother / father / guardian) What language did your child first understand and speak?
seldom / sometimes / often / always Which language do you use most with your child?
Which other languages does your child know? (circle all that apply)
Which languages does your child use? (circle one)
speak / read / write speak / read / write Will you require written information from school in your native language? Y N Parent/Guardian Signature:
X
seldom / sometimes / often / always seldom / sometimes / often / always Will you require an interpreter/translator at Parent-Teacher meetings? Y N / Today’s Date:
/20 (mm/dd/yyyy)
Encuesta del idioma hablado en el hogar Los reglamentos del Departamento de Educación Primaria y Secundaria de Massachusetts exigen que todas las escuelas determinen los idiomas que se hablan en los hogares de los estudiantes para así identificar sus necesidades específicas relacionadas con el idioma. Esta información es esencial para que las escuelas puedan proveer instrucción que todos los estudiantes puedan aprovechar. Si en su hogar se habla otro idioma que no sea inglés, se requiere que el Distrito evalúe a su hijo más a fondo. Ayúdenos a cumplir con este importante requisito respondiendo a las siguientes preguntas. Gracias por su ayuda.
Información del estudiante Nombre
Segundo nombre
País de nacimiento
/ / Fecha de nacimiento (mm/dd/aaaa)
F Sexo
Apellido
M
/ / Fecha de matriculación inicial en CUALQUIER escuela de EE.UU. (mm/dd/aaaa)
Información de la escuela / /20 ______ Fecha de comienzo en la escuela nueva (mm/dd/aaaa)
Nombre de la escuela y ciudad anterior
Grado actual
Preguntas para los padres/encargados ¿Cuál es el idioma natal del padre/la madre/los encargados? (encierre en un círculo) (madre / padre / encargado)
¿Qué idioma(s) se habla(n) con su hijo? (incluya parientes -abuelos, tíos, tías, etc. - y encargados del cuidado) infrecuentemente / algunas veces / frecuentemente / siempre
(madre / padre / encargado)
infrecuentemente / algunas veces / frecuentemente / siempre
¿Cuál fue el primer idioma que entendió y habló su hijo?
¿Qué idioma usa usted principalmente con su hijo?
¿Qué otros idiomas sabe su hijo? (encierre en un círculo todo lo que corresponda) habla / lee / escribe
¿Qué idiomas usa su hijo? (encierre uno en un círculo)
habla / lee / escribe ¿Requerirá usted la información impresa de la escuela en su idioma natal? Sí No Firma del padre/la madre/encargado:
X Spanish
infrecuentemente / algunas veces / frecuentemente / siempre infrecuentemente / algunas veces / frecuentemente / siempre ¿Requerirá usted un intérprete/traductor en reuniones de padres y maestros? Sí No / Fecha de hoy:
/20 (mm/dd/aaaa)
ATHOL-ROYALSTON SCHOOL DISTRICT Student’s Name:____________________________________________ Grade:_____________ Please answer BOTH question 1 and 2.
1) Is this student Hispanic or Latino? (choose only one)
! No, not Hispanic or Latino
! Yes, Hispanic or Latino (A person Cuban, Mexican, Puetro Rican, Cuban,
South or Central America, or other Spanish culture or origin, regardless of race.)
2) What is the student’s race? (choose one or more)
! American Indian or Alaska Native (A person having origins in any of the original peoples of North or South America (including Central America), and who maintain a tribal affiliation or community attachment)
! Asian (A person having origins in any of the original people’s of the Far East, Southeast Asia, or the Indian subcontinent including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam)
! Black or African America (A person having origins in any of the black racial
groups of Africa)
! Native Hawaiian or other Pacific Islander (A person having origins in any of
the original peoples of Hawaii, Guam, Samos, or other Pacific Islands) ! White (A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa)
Parent/Guardian Signature:_____________________________________________Date:____________
