EFTA01709788.pdf

EFTA01709788 EFTA01709789  STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILIT ATIVE SERVICES Special Health CUMULATIVE SCHOOL HEALTH RECORD Problems - See (This form Is not intended for physician's use) Narrative. Warn Race Sex • S Address Father's Name Mother's Name Date of Birth Place of Bin Birth Recorded; Yes 0 No 0 Immunization Certification: Yes 0 No 0 Special Immunization Programs A NARRATIVE NOTE IS REQUIRED FOR REFERRAL AND OUTCOME ENTRIES K 1 2 3 Screening and Outcome . Screening Assessment ' Screening Referral Outcome c Screening Referral Outcome Date Grades E" 4. Date g 1, Date .9 us K-3 20 I; 8 8 0 a) S a> CO Ce 0 CC Vision ...s" -,7 fa /O Hearing I. .0 Height, Weight & Graphing Nutrition /196 Dental Health Mental Health Communicable Disease Records Review Physical Assessment Other Other 4 5 6 Screening and 7 8 [Screening Assessment Screening Outcome Screening Screening Outcome Screening Outcome Referral 13 Outcome Referral Outcome -0 Date P Referral Grades Date Date Date ::15 Date 4-8 8 0 .3) it ec If /ision (J-115.7) -tearing r I I SICIR P ieight, Weight -it- 43 14 - &Gra•hin. W• lutrition rental Health 'lent& Health communicable Disease lecords Review hysical Assessment coliosis 'ther ther 1S-H Form 3041. MAY 80 (Replaces nravinlio tadifinne ....a • ant nn EFTA01709790  FLORIDA Verification of R 1111 Fr II I eceipt (NOTE: This Is no • t the application for the scho larship.) I verify that I ha ve received and re 44 of the Florida Bright Fu ad the initial eligib tures S ility requirements r the year 2004. Name or Signature SCHOLARSHIP PROGRAM Date Please return to yo ur high school gu idance counselor EFTA01709791  THE SCHOOL DISTRICT OF 1997-1998 END-OF-YEAR REPORT IIIIIIIIINME.".....,,•••• Elementary School school In a continuing effort to keep you informed, this report card insert is being provided to notify you of your child's progress toward meeting the school district's desired levels of performance in reading, writing, and mathematics. Your child's end-of-year performance level in reading, writing, and mathematics is identified below. READING WRITING (COMPOSITION) MATHEMATICS EKAt or above grade level L1 At or above grade level ErAt or above grade level El Below grade level* El Below grade level* ❑ Below grade level* *If Below grade level has been indicated for reading, writing, and/or mathematics, you will be asked to participate in the development of a plan to improve your child's academic performance. This plan will be developed at the beginning of the 1998-1999 school year. EFTA01709792  SEX RACIAL/ETHNIC GROUP U Hispanic STUDENT NUMBER MVVhite, Not Hispanic O American Indian/Natiye Alaskan O Black, Not Hispanic • Asian/Pacific Islander ADDR al) Verified by Birth Certificate: O Yes . , . If Not, What Type Verification? • • NA THER RESPONSIBLE ADULT AT HOME: P G OA I s .11:01•4:1•141•111116•111.1.10100•11101.61•11.-11.•• . I Name ma - .4 Street Date First Entered This District Withdrawal Date Withdrawal Date, Withdrawal Date City /.._Q-4. f g —q - 1. , Grade: Grade Grade: Grri4 dr : School Year: 19- 19.94 School Year: 19 93 -19 4/,‘ School Year. 19 -19 (4 5 School Year: 19 I -19 School Year -19 - 9 .7 Days Present: Days Absent: Days Presem: Days Abient Days Present: Days Abukir. Days Present. Days Absent: Days Present: Days Absent: (4,(0 Subject Teacher 4 Mark i , 2- Subject 11 .3 • Mik 1113 Subject '1 Teacher I ark AR Subject // Teacher Mark I'D I Subject \-3 Teacher 1,y ark MATHEMATICS MATHEMATICS MATHEMATICS MATHEMATICS II MATHEMATICS READING READING READING READING READING a LANGUAGE SPFU-ING HANDWRITING LANGUAGE SPELLING HANDWRITING LANGUAGE SPELLING HANENVRITING JANGUAGE SPELLING HANDWRITING C...- C...• LANGUAGE SPELLING HANDWRITING N, _ROCK! STUDIES SOCIAL STUDIES SOCIAL STUDIES ‘6 - SOCIAL STUDIES 7:1 SOCIAL STUDIES % SCIENCE and SCIENCE and 6 SCIENCE and V SCIENCE and 3 SCIENCE and • 'FS _HEALTH BEHAVIOR CODE AVERAGE 3 JiEALTH BEHAVIOR CODE AVERAGE ..3 . HEALTH BEHAVIOR CODE AVERAGE. HEALTH BEHAVIOR CODE AVERAGE 3 HEALTH BEHAVIOR CODE AVERAGE 3 ind,cine: Indicate: p Indicate: p Indicate: Promote (P) ? Indicate: Promote (P1 Promote IP) Promote DPI Promote IP) tp IP FLORIDA PERMANENT RECORD CARD Retain (RI Retain (R) Retain (R) Retain (R) Summer sow, (S51 Summer School (SS) Summer Shod as Retain (R) sworn., School MS) Summer School MS/ Grade: Schoot (Grade: School: (Grade: School: (Grade: School: (Grade: CATEGOAY A - Education Records OS— • School Year 19- C -19 G School Year 19_•19 School Year 19 -19— School Year 19_-19— School Year 19 .19 Days Present Days Absent: Days Present: Days Absent: Days Present: Days Absent: Days Present: Days Absent: Days Present: Days Absent: /1 1 q Subject Teacher Mark Subject Teacher Mark Subject Teacher Mark Subject Teacher Mark Subject Teacher Mark MATHEMATICS 9 ) MATHEMATICS MATHEMATICS MATHEMATICS MATHEMATICS READING READING READING READING READING LANGUAGE c.l- LANGUAGE LANGUAGE LANGUAGE LANGUAGE SPELLING C.• SPFLI ING SPELT ING SPED ING SPELLING HANDWRITING d HANDWRITING HANDWRITING HANDWRMNG HANDWRITING SOCIAL STUDIES r, SOCIAL SH.IDIES SOCIAL STUDIES SOCIAL STUDIES SOCIAL STUDIES GRADES K-5 SCIENCE and 0 ISi kEiNCE and SCIENCE and SCIENCE and SCIENCE and HEALTH HEALTH . HEALTH HEALTH BEHAVIOR CODE . s.. BEHAVIOR CODE BEHAVIOR CODE BEHAVIOR CODE BEHAVIOR CODE AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE Indicate: Indicate: Indicate: Indicate: Indicate: Promote IP) Promote (P) Promote (P) Promote (P) - Promote (P) Retain IR) Retain (R) Retain Mr Retain (R) Retain (A) - 01-93d0 EFTA01709793  FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, s. 64D-3.011, F.A.0 and s. 65C-22.006, F.A.C. LAST NAME J FIRST MI DOB MO/DMYR PARENT OR GUARDIAN Child's SS# (optional) SEA IF imMt UATION ID# DirettionC • Enter all appropriate doses and dates below. • Sign and date appropriate certificate (A-I, A-2, R. or C) on reverse side of form. • If the child is pnw•nting for the 7th grade requirement only and has preciously filed a Certificate of Immunization (680A or 680A-I) with their current Florida school, fill in boxed areas below and complete Part .t-2 on the reverse side of this form. For additional information: See Immunization Guidelines for School and Child ('are Facilities for information and instructions on form completion and immunization requirements. Guidelines are updated annually and are mailable from the local county health department. VACCINE. DTaP/DTP2 DT3 Td' Polies HIB` MMR (Combined)' (Separate)' Hepatitis B' The state immunization ID# is an identifier supplied by the state immunization registry (optional). 2 DTP 5 doses required. If the fourth primary dose is administered on or after the fourth birthday a fifth dose is not required. DTaP is an acceptable alternative for one or more doses of DTP. DT (pediatric) is acceptable if Pertussis vaccine is medically contraindicated. (Complete Part C for Pertussis contraindication.) 4 Td (Adult) Vaccine is recommended for children 7 years of age or older. s Polio 4 doses required. If the third dose is administered on or after the fourth birthday. a fourth dose is not required. IPV is an acceptable alternative for one or more doses of OPV. Polio vaccine is not required for children 18 years of age or older. 6 Hib is required for child care and preschool entry and attendance only. 7 1st dose valid if given on or after 1st birthday. Second dose (measles) valid if given at least I month after Ist dose. A second dose of measles (preferably MMR) is required for students in grades K-4 in the 1997-98 school year, and 7th grade entry and attendance effective with the 1997/98 school year. In each subsequent year thereafter, the next highest grades are included. Includes single measles vaccine (6), single mumps vaccine (H) or single rubella vaccine (I). 9 Hepatitis B vaccine series is required for seventh grade entry and attendance effective with the 1997-98 school year and kinder- garten entry and attendance effective with the 1998-99 school year. In each subsequent year thereafter, the next highest grades are included. EFTA01709794  LAST NAME FIRST Mi DOB (MO/DAIVR) Certificate of Immunization for K-12 ExcludIng7th Grade Requirements PART A-1 (Immunizations are complete for school entry and attendance grades kindergarten through 12 with the exception of the 7th grade requirement.) DOE Code I I have reviewed the records available, and to the best ofmy knowledge, the above named child has been adequately immunized against diphtheria, tetanus, penussis, polio, measles, mumps, rubella and hepatitis B (for kindergarten effective with the I998.199 school year)for school attendance as docurnemed on the reverse side of this form. Physician or Clinic Name: Physician or (Print or stamp) Authorized Signature. Address. Date. Certificate of Immunization Supplement for 7th Grade Requirement Part A-2 (immunizations are complete for students who enter or attend the 7th grade after the beginning of the 1997/98 school year. Each subsequent year thereafter, the next highest grade will be included in the requirement.) DOE Code 8 I have reviewed the records available, and to the best ofmy knowledge, the above named child has received thefollowing immunizations requiredfor entry and attendance in 7th grade effective with the 1997.98 school year: tetanus-diph and second dose of measles vaccine as documented on the reverse side of this form (boxed areas Physician or Clinic Name: Physician or (Print or stamp) A thorized Signature: Address Date. Temporary Medical Exemption PART B (For preschool children, children in day care and school children who are incomplete for immunizations in Part A-I or A-2.) Invalid without expiration date. DOE Code 2 I certify that the above named child has received the immunizations documented on the reverse side of this form and has commenced a schedule to complete the required immunizations. Additional immunizations are not medically indicated at this time. Physician or Clinic Name: 7r-r-7 7;""—Expittition Date: (Print or Stamp) (I5 days after net immunization appointment) Physician or Address: Authorized Signature. Date. Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 1certify that he physical condition of this child is such that immunizationts)as indicated in Part C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature. Address: Date. flit 610. 8:98 , replace, earlier edition, i Shwa. unibtr : 5740400•06110-40 EFTA01709795  THE SCHOOL DISTRICT OF • NEW/RETURNING STUDENTS REGISTRATION BACK ---- I 131) STUDENT uves WITH ICHECIL OKI RI BOTH PARENT} ❑ MOTHER (33) "IlAkSPEATE3 DE 6441/43 ,.I 54 InNopomo4 lo/Lom, schml In Comm N ether dm. pmon0 II FATHER 9 SHARED CUSTOOT 0 011iePt 1331 13 THERE A COURT ORDER BARRIO EITE4R PARENT FROM Ilf/A0EIN4221 0 YES IS NO CONTACTING THE STUDENT DLIRING DIE SCHOOL DAY> 2.1 4/35 IF YES, PLEASE PROVIDE THE SCHOOL WITH A COPY OF THE COURT OROFR 13A) FATHER/GUARDIAN DOES FATHER HAVE CUSTODY> DYES in NO 1351 MOTHER/GUARDIAN DOES MOTHER HAVE CUSTODY> 0 ',Es 0 NO YES YES ..., TA.. AQUA LAST OPST WA NOW Lau ST ICF0.'non va.s4 Tar RAU OS INII.004INT RAU CV INP.OTHINT M l. Ill IIIIMOSS 443.4 NIGH I VVL U A N l H. t 1 I It 0 A0 0...• lmom SOFFAX B0 SORK FRO. Slat iosAFE, T. of C D .soar° A. O'N ,A El 0.04INTOIT 1004 Amman T.* B El SOW re SPOOF Tanta • FFF c 11t"---. D0 Tom Tost-FavAwr E0 TOFEFAA•mtFT•FF.Fm D soma rOsTF2ECONCART E II COADUATI " c' ICAcc."“ (ITOFAICAUCOU1411) RHAFAIS or MOW rrecooscAUcoasoc •• ESORIT 1361 LEGAL GUARDAN (IF AND DOES LEGAL GUARDIAN NAVE CUSTO ❑ Y D NO num RANI MOORS t. CCOSETTTA MALL Of LISEDDLINT , ITALALIS MY EMERGENCY HEALTH AND SAFETY INFORMATION PART I PC4500151 P 139/ PASSWORD 'Liu T I) C0ARACTERSI (40 mincsalo Poi ellINIIN(Y nba, 14'I NAME PHENF RR AT IONSHLP En an YES -racielonoin E] NO ADDRESS RE.ATIONSHW F—D y YES AuA+ ENO ADDRESS RELATIONSHIP ILA YES riethei 0 No ADDRESS N. RE.ATONSHIP r•I U YES No