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1 REGISTRATION CENTER PS #3 ANNEX 5401 Polk Street West New York, NJ
2 WEST NEW YORK BOARD OF EDUCATION SOLICITUD DE ADMISION Kindergarten Grade 12 For Office Use Only District: Student ID #: ELEMENTARY MIDDLE SCHOOL HIGH SCHOOL INDEX OF THE PAGE IMPLEMENTATION PROVISIONS TO THE PROCEDURE OF THE PROCEDURE OF THE PROCEDURE OF THE PROCEDURE OF THE PROCEDURE OF THE PROCEDURE If you suspect that your child between the ages of 3 to 21 may have some incapacity or impairment that makes it impossible or affects your learning and, you are a resident of West New York, you can contact the West New York Department of Education Special Services Office. The Department of Special Services may provide you with information regarding the services for which your child may be eligible. By FAVOR LLAME A: Beverly M. Lazzara, Director of the Department of Special Services (201) , Ext If you have any difficulties with the process of the Enrollment, please contact Maria A. Brizuela at (201) for assistance. PS #3 ANNEX 5401 Polk Street West New York, NJ

3 Dear Father/Guardian, LIST OF VERIFICATION FOR MATTERS Kindergarten Grade 12 Please submit the following documents, forms and full policies when you come to the Enrollment. For your convenience, find below a checklist for the Tuition. Admission application must be filled completely Original Birth Certificate Translation Certified in English of the Birth Certificate that is in another language Students with Transfer have to Present: Transfer Card/ Transcription/Academic Qualifications of the Previa School Two (2) Recent and Acceptable Tests* of Residence address in West New York *Please make sure all the internet tests submitted by address are original accounts received by mail, and not through the mail. Two (2) Pictures of the Student Passport Size The following forms and policies: These Forms and policies must be filled and signed by the Father/Guardian. Policy on the Acceptable Use of Computer Authorization to Publish Photos or Videos of the Student Policy About the Use of Drugs and Selection of Doctors Annual Notification of Medicaid/SEMI Parent Consent Form Medical History of the Student Health Schools Authorization to Exchange Confidential Information Form of the Student Medical/Fistical Test Forms These medical forms must be filled Immunization Test IMPORTANT NOTE Only the Father/Guardian can entangle the Student. Father/Guardian needs to show valid ID with photo when he comes to the grid. PRELIMINARY INFORMATION: FOR LÉAL FAVOR BEFORE CONTINUING 1. The district must accept from people trying to demonstrate the eligibility of a pupil in the district a combination of any of the following documents, or similar documents; a. Receipt of property taxes, title of property, contract of sale, lease, mortgages, letters signed by the owner, or other evidence of property, lease or domicile; b. Voting registration, licenses, permits, bank accounts, receipts of utilities, receipts of deliveries, or other evidence of your connection to an exact location; c. Judicial orders, contracts of a state agency, or other evidence of the court or provision of any agency or directives; d. https://jbhnews.com/8-%cf%83%cf%85%ce%bc%ce%b2%ce%bf%cf%85%ce%bb%ce%ad%cf%82-%ce%b3%ce%b9%ce%b1-%cf%84%ce%b7%ce%bd-%ce%bf%ce%b9%ce%ba%ce%bf%ce%b4%cf%8c%ce%bc%ce%b7%cf%83%ce%b7-%ce%bc%ce%b5%ce%b3%ce%b1%ce%bb%cf%8d%cf%84/99870/ , invoices, accounts, cancelled checks or other evidence of expenses that demonstrate your connection to an exact location, or to be appropriate for student support; e. https://jbhnews.com/de-basta-kosttillskotten-for-att-fa-en-strimlad-och-sliten-atletisk-kropp-pa-4-veckor/41187/ , assessments of counselors or social workers, employment documents, unemployment claims, benefits account, or other evidence of circumstances that demonstrate when appropriate, family problems, economics or temporary residence; f. Affidavits, certificates and jury testimonies related to statutory actions for school attendance by the parent or legal guardian, the person who maintains a student under affidavit, person(s) with whom a family or others lives as appropriate; g. Documents relating to their military status and assignment; and h. Any registration or document of a government agency. 2. The district may accept documentation not mentioned above, and should not fail to consider any documentation or information submitted by a person who wishes to enrol a student. 3. The district shall consider the information and documentation provided by an applicant, and shall not deny registration if any document or information is missing without first considering all the evidence presented. 4. The district shall not require or request as a requirement for school enrolment, any information or document that is protected by law to be disclosed, or documents on information that are not regulatory to determine the eligibility of school attendance. These include but are not limited to: a. Tax statements; b. Documents or information related to citizenship or immigration/visa, except as set out in law N.J.A.C. 6A:22-3.3(b); c. Documents or information related to compliance with local housing or lease conditions; and d. Social Insurance Number 5. Documents or information referred to in paragraph 4, or relevant parts of any of these documents may be considered by the district if they are voluntarily submitted by the person requesting registration. However, the district cannot, directly or indirectly, demand or request that these documents be submitted as a condition for obtaining the registration. 4

6 REGULATIONS ON THE USE OF UNIFORME (All grades Pre-Kindergarten 12) Shirts: The colour pullovers that identify the school and the official school badge will be allowed, can be short or long sleeves. Individual schools along with the Superintendent will designate the color of the shirts for each school. Trousers/faldas: They will be allowed/faldas of kaki, blue, or black cotton. The trousers/faldas must have the right size and the length must be in accordance with these Regulations. Cowboys or trousers / skirts of peach are not considered appropriate clothing according to these regulations. JBHNews : Uniforms for Physical Education (e.g., sweatshirts, short run trousers) are not mandatory. If you buy the physical education uniforms, these must be the color assigned to the school. We ask parents to buy the right uniform from the providers designated by the District, however the right uniform can be purchased wherever this type of clothing is sold. Cover Stitches J & S Finishing Inc. Teddy Castro Pedro Calvo th Street nd Street West New York, NJ West New York, NJ Phone: Phone: Fax: Fax: Please plan according to these regulations. 5

7 POLICE ON THE ACEPTABLE USE OF THE COMPUTER This is a summary of the policy on the acceptable use of the communication/computer network and district resources. The district requires that all students and their parents, mothers, or legal guardians read the policy as a whole, which appears on the district website, or may request a copy to the school director. The Board of Education recognizes that the way in which telecommunications and other technologies change the way information is obtained, communicated, and transferred may alter the form of teaching and learning. Access to telecommunications will allow students to explore databases, libraries, Internet sites, advertisements, and all that involves sharing information with other people around the world. The Board supports that students have access to information sources, but reserves the right to limit the appropriate use of materials for educational purposes. The Board provides access to the communication/computer network only for educational purposes. The Board reserves the right to restrict or revoke students ' access to the communication/computer network at any time and for any reason. The Board reserves the right for trained district staff to control the activity on the network, in any way necessary to maintain the integrity of the network and to ensure that it is being used properly. No student will be allowed to use the local communication network and the Internet, unless they have the authorization form signed by parent/legal guardian. The Board also recognizes that telecommunications will give students access to sources of information that have not been previously examined by teachers according to board policies. The Board has adopted codes of conduct for the use of the communication network, and declares nonethical, unacceptable, or unlawful conduct as a fair cause for disciplinary action, restriction, or revocation of the privileges of access to the communication network and/or legal action. The explanation of these codes appears in the Policy and Regulation This policy also institutes procedures and provisions in the district for Internet security as required by the Law on Protection of Children's Inmediations on the Internet. Apart from blocking and filtering the visual representations prohibited in the Child Protection Act on the Internet, the board must determine that other materials on the Internet are inappropriate for minors. The Board will provide a public announcement and conduct a public hearing during the Board ' s monthly meeting or during a special meeting of the board to present and receive the community ' s opinion on the Internet Security Policy Policy Policy and Regulation Violations of the 2361 policy includes but is not limited to suspension or revocation of privileges to use the computer, expulsion from the school, or legal and enforcement action by the authorities. My signature indicates that I have read and understand the West New York Policy on the Acceptable Use of the Computer. Student Name (mouldle): Father/Guardian Name (mouldle): Father/Guardian Signature: Date: School: 6

8 AUTHORIZATION TO PUBLIC PHOTOS OR VIDEO OF THE STUDENT Often during the school year students participate in different school activities such as assemblies, special projects, etc. in which photographs are taken. These photographs are sometimes published as part of articles in newspapers or on television, with the purpose of highlighting the achievements of our schools. These images can also be used for internal training of our teachers and staff. In addition, sharing your images, we would like to let you know that your child was part of the District World Education Movement. Students in our district will use equipment that can capture your image for publication, including but not limited to portable cameras, laptops, computer-connected cameras, cell phones, video cameras, and recording equipment. Your child's images and works can be shared through the different media, including but not limited to: District Internet page, distance training, project-based content, educational communication networks, school yearbooks, assemblies, student achievements, and/or District newsletters. Please indicate below if you authorize or not your child to be photographed: According to the Education Board Policy 9120 and 9400, you are required to authorize the District to photograph your child. By filling out jbhnews.com are giving your permission for the District to photograph or post your child's image. I authorize my child to be photographed or recorded while in school. I do not authorize my child to be photographed or recorded while in school. Student Name (mouldle): Father/Guardian Name (mouldle): Father/Guardian Signature: Date: School: 7

9 POLICE ON THE USE OF DROGAS The West New York Board of Education has an obligation to protect its students from drug use. Our teachers in addition to providing quality education are instructed to determine when a student shows signs of being using drugs. Any student who is found drugs in his possession or who is under the influence of drugs, alcohol or steroids within the school property or at any event organized by the school will have to immediately pass a medical examination as ordered by the law of the State of New Jersey 18A: 40A-12. The medical examination shall be ordered by the school director or his/her designate. The medical test should consist of a physical examination, a urine test to detect drugs, and/or an examination to detect alcohol breath. The West New York Board of Education has selected a medical centre where such students can be examined for drug use at no cost to parents or guardians. https://jbhnews.com/crazy-bulk-gynectrol-a-natural-supplement-for-gynecomastia-treatment1/39379/ or guardians may determine to take their children to take these tests with another doctor other than the one selected by the West New York Education Board. If JBHNews choose another doctor who is not the one selected by the West New York Education Board, you are required to comply with the following laws: 1. The parents or guardians of the student shall be responsible for the payment of medical examinations performed by another doctor other than the one designated by the Education Board. 2. The doctor selected by the parents must be available to examine the student immediately. If the doctor is not available to examine the student immediately, the student will be taken to the doctor selected by the West New York Board of Education; and 3. The doctor has to send a medical report to the school director and to the parents or guardians of the student within 24 hours of the examination. The student may not return to classes until the doctor who attends him reports that drug use no longer interferes with his ability to behave at school. Parents or guardians who select their own doctor, in doing so certify that the doctor is willing, able and will comply with the standards required by the law to which we refer in the preceding paragraphs. Parents or guardians who do not comply with the laws of N.J.S.A. 18A: 40A-12, will be violating the compulsory law of education (N.J.S.A. 18A: 38-25) and/or the law of abandonment of children (N.J.S.A. 9: 6-1 et seq.). This document is a summary of the District's #5530 Policy on Substance Abuse. The student and his father, mother, or guardian are responsible for reviewing this policy as a whole, which appears on the District's website, and is required of them to comply with all aspects of the #5530 policy. My firm indicates that I have read and understand the West New York Policy on Drug Use. Name of the Student (mouldle): Name of the Father /Guardian (mouldle): Signature of the Father/Guardian: Date: School: MEXICO SELECTION I understand that the law of the State of New Jersey, N.J.S.A. 18A: 40A-12, requires the Board of Education to conduct an immediate medical assessment of my child for possible drug use if my child is in possession of drugs and/or has symptoms associated with the use of drugs, alcohol, and/or steroids. I understand that the school director or his designate will communicate with me immediately to inform me that my child has been found with drugs in his possession and/or with symptoms related to drug use, alcohol and/or steroids and that a medical examination to determine whether my child has been drug abused will be immediately practiced with the doctor I select below. My phone during the day is: My phone during the night is: If my child, (A student's name), requires a medical examination to determine whether he or she has been using drugs during the school year, I by this means designate the doctor to do a medical examination and an analysis to determine drug use. Doctor selected and paid by the Board of Education: CONCENTRA WEST NEW YORK 6701 Bergenline Avenue West New York, NJ Doctor of my selection by which I will pay: Doctor's name: Doctor's address: Doctor's phone: Student's name: Father's name/guardian: Parent's signature: Date: School: Partial Notification The SEMI program works with the sponsorship of the New Jersey Treasury Department in collaboration with the New Jersey Department of Education and the Medical Assistance and Health Services Division (DMAHS) in New Jersey. In 2013, the rules relating to the consent of the parents required by Medicaid were reformulated for the services provided in schools. Currently, the legislation requires that before accessing a child ' s public benefits or insurance for the first time and, subsequently, every year, school districts must send parents or guardians a written notice and obtain parental authorization for the sole time. Is there a cost to you? No. IEP services are provided to students at school at no cost to parents or guardians. How could SEMI affect the benefits my family receives from Medicaid? The SEMI program does not affect Medicaid services, funds or coverage limits for families. The service program offered in New Jersey schools works differently than the Medicaid program for families. The SEMI program does not affect Medicaid benefits for your family in any way. What kind of services does the program offered at school cover? Evaluations Language Therapy Occupational therapy Psychological counseling Hearing Specialized transportation Physical therapy What kind of information about your child could be disclosed? To submit claims to SEMI, you may need to provide the following data on your child: first name, second name, last name, address, date of birth, student card number, Medicaid ID number, type of disability, dates and type of services provided. Who could have https://jbhnews.com/clenbuterol-gel-difference-between-clenbuterol-tablets-claire-gel/29857/ to that information? Information about your child's special education program can be shared with the New Jersey Medical Assistance and Health Services Division and its affiliate agencies, including the Treasury Department and the Department of Education, with the aim of verifying Medicaid's eligibility and filing claims. What if you change your mind about the consent granted? You have the right to withdraw your consent that allows the billing to Medicaid at any time, contacting the school where you are enrolled your child. Could the services your child receive when you grant or deny your consent be affected? No. JBHNews should continue to provide the necessary services to your child in accordance with its IEP, regardless of its eligibility status with Medicaid or its decision to give your consent to the SEMI billing. What if you have any questions? Please call the West New York School District Special Education Department if you have any questions or concerns or if you need to get a copy of the parental consent form. Notification

12 Special Education Medicaid Initiative (SEMI) Parental Consent Form Our school district participates in the Medicaid Special Education Initiative (SEMI) program, which allows school districts to bill the Medicaid health program for services offered to students. According to the Federal Law on Education and Family Privacy (FERPA), 34CFR and Part B Section 617 of the Law on the Education of Persons with Disabilities (IDEA), for its English acronyms) on consent requirements in 34 CFR, a unique consent is required before accessing public benefits. This consent states that your child's personal data, such as your school history or information about the services provided to you, including the specific evaluations and services of the Individualized Education Program (IEP), which your child receives (a) ( Occupational therapy, physical therapy, speech therapy, psychological therapy for students, audiology, nursing, and specialized transportation), can be disclosed to the Medicaid program and to the Medical Department. As a parent/stutor of the minor named below, I give permission to disclose the information described above; as well as I understand and accept that Medicaid may have access to public or secure benefits my child or mine to pay for the special education and related services under Part 300 (services under IDEA). Name of the child: Date of birth of the child: *I give my consent to invoice the SEMI: Yes No Signature of the Father/Tutor: Date: This consent may be revoked at any time, contacting the person in charge of the case of your child or the special education department of West New York. SEMI Parental Consent

13 MESSICAL HISTORY OF THE STUDENT Dear Father/Guardian, Please complete this brief medical history on your child. Answer JBHNews . This information will be shared only with the school staff who need it. Thank you. Student Name: Date of Birth: 1. Allergies to some food: Yes No Yes Yes, which: 2. Allergies to Medicines: Yes No Yes Yes, Which Medicine: 3. Allergies to insects: Yes No Yes Yes, what class: 4. Allergies to animals: Yes No Yes, it is, as an animal: 5. https://jbhnews.com/cutting-steroids-safe-and-effective-weightloss-steroids-for-quick-and-spectacular-results/29988/ : Yes No Yes, which allergies: 6. Asthma: If not, use your child a medicine machine: If not, how often do you use it: 7. Heart Problems: If Not Yes, What Problem: 8. High Fever Convulsions: Yes Not How high the temperature comes: When the last one was: 9. JBHNews : Yes No If it is yes, what class and when: 10. Hospitalized: Yes No Yes Yes, because: 11. Heridas: Yes No Yes, what class and when: 12. Points: Yes No Yes Yes, where and how many: 13. JBH News of bones: If not, what and when: 14. JBHNews in the ears: Yes No. 15. Frequent throat infections: Yes No 16. Skin rash: Yes No If it is yes that class: 17. Your child has had chickenpox, measles or mumps: Yes No Yes Yes Yes, Which And When: 18. Take your child some medicine other than vitamins: Yes No Yes Yes, the name of the medicines: 19. You have your child some restrictions on doing physical activities: If not, say what are the limitations of the activities: 20. He has his child some other health, emotional, or behavioral problem now or in the past, that we should know: If not, what are: 21. Use your child or contact lenses: Yes No. 22. Use your child's hearing aids (hearing aids): If not, what kind: 23. Use your child's cane, crutches or wheelchair: If not, which of them and for: 24. You have your child some special needs: Yes No Yes Yes, what type: 25. In his family someone has suffered from Diabetes: Yes No. 26. In your family someone has suffered from Cancer: Yes No. 27. In https://jbhnews.com/losing-weight-the-hollywood-way-with-clenbuterol/44105/ has suffered or had problems with seizures: Yes No. 28. In your family someone has or has had heart problems: If not, what kind of problem: 29. In your family someone has suffered from High Pressure: If you do not sign the Father/Guardian: Date: . You suffer your child from a chronic medical problem, special needs or some kind of disability? If No If yes, please indicate the problem or condition in a mould letter: 2. Has your child a Individualized Health Plan (e.g., Asma, Attacks, Diabetes, Severe Food Allergy) of another School District? If not, please provide https://jbhnews.com/forskolin-reviews-forskolin-250-for-weight-loss/41625/ of the Plan. 3. Does your child have Plan 504? If not, please provide a copy of the Plan. 4. Does your child have an Individualized Education Plan for Special Education of another School District? If not, please provide a copy of the Plan. 5. Do you have your child's medical insurance including NJ FamilyCare/Medicaid, Medicare, Private Insurance or other Medical Insurance? If yes, Insurance Company Name: No NJ Family Care, provide free or low-cost health insurance for minors and for some low-income parents. For more information, call or visit the Internet page to fill out the form. I authorize the NJ FamilyCare Program to provide my name, address, and if my child receives free lunch, or at a reduced cost to communicate with me in relation to health insurance. Student Name (mouldle): Father/Guardian Name (mouldle): Father/Guardian Signature: Date: School: HEALTH SERVICES Authorization To Exchange Confidential Information Student Name: Date of Birth: (mouldle) Date: Classroom: As a parent/guardian of the student whose name appears in this document, I authorize the student to exchange the appropriate medical allergy (input with appropriate student care). This consent is valid for the school year and it is for the purpose that the staff can offer my child a better service. Parent/Guardian Name: Father/Guardian Signature: (For Office Use Only) Information given to Parent/Guardian/Information administered to the Father/Guardian Asthma Action Plan/Plan for the Treatment of the Asthma Allergy Action Plan/Plan for the Treatment of Allergies Seizure Action Plan/Plan for the Treatment of Convulsions Medication Permission Form/Permissive for the Management of Medicines Physical exam test in the last six months Medical/physical exam form - (THE 2 POPULATION PAGINAS OF BE LLENADA, FIRMADAS AND SELLADAS) These medical forms must be filled, signed and sealed by a doctor and also FEEL that they should be reviewed, approved and signed by one of the WNY School Nurses prior to making the Enrolment. Required Immunization Test: Visit your local health center: Immunization against Diphtheria, Tetanus, and Tosferin (DPT or DTaP) four (4) doses. One (1) dose should have been given when you reach 4 years or later or any of the five (5) doses. If the Series started after the age of 7 years, it only needs three (3) Tétano Difteria, (Td). Immunization against the Polio (IPV) three (3) doses. One (1) dose should have been given when you reach 4 years or later or any of the four (4) doses. If you started after the age of 7 years, you only need three (3) doses. Immunization against Rubeola, Measles, and Paperas (Rubella) (MMR) two (2) doses. The first dose should have been given at 1 Year or later. The second dose should be required before beginning Kindergarten or after 4 years. Instead of the second dose, you can bring documented Blood Test (Titer). Influenza immunization Haemophilus Type B minimum one (1) dose. Minimum one (1) dose between the age of 12 to 59 months. It can't happen after 5 years of age. Immunization against Hepatitis B three (3) doses. Immunization against Varicela one (1) dose. JBH News (1) dose must have been given at 1 Year or later. https://jbhnews.com/ectomorph-bodybuilding-workout-and-diet-guide-ectomorph-bodybuilding1/33541/ is recommended. Pneumoccal (Pcv 13, 21 or Prevnar) one (1) dose. If you were given Pcv 7, at least one (1) dose should be Pcv 13. After the first birthday. jbhnews.com . The test has to have been administered in the last six months before entering school, whether it has been born in a high incidence country or has a positive result in the Tuberculosis test on the skin. If you have left the country for more than 3 months to another high incidence, you need new Mantoux test. STUDENT TO 6th GRADO OR NACIDOS AFTER JANUARY 1, 1997 MUST HAVE Tdap (DIFTERIA, TÉTANO AND PERTUSIS) AND MENINGOCICA. STUDENTS THAT HAVE RECEIVED THE FIRST DOSIS OF THE VACUNA AGAINST HEPATITIS A, THE SECOND DOSIS shall be RECEIVED. REQUERED IMMUNIZATIONS PUEDEN VARIAR DEPENDING THE STATAL MANDATES. THE NUEVOS O TRANSFERS OF THE LISTED COUNTRIES ARE NOT REQUIRED OF TB STUDENTS OR TRANSFERS OF THE LISTED COUNTRIES ARE EXENTS OF THE MANTOUX TUBERCULOSISED PROGRAMMES Albania America Samoa Andorra Antigua and Barbuda Australia Austria Barbados Belgium Bermuda British Virgin Islands Canada Cayman Islands Chile Cook Islands Costa Rica Cuba Cyprus Czech Republic Denmark Dominica Finland France Germany Greece Greenland Grenada Iceland Ireland Israel Italy Hungary Jamaica Jordan Lebanon Luxembourg Malta Monaco Monserrate Netherlands Antilles New Zealand Northern Ireland Norway Oman Puerto Rico Saint Kitts and Nevis St. Lucia Samoa San Marino Slovakia Slovenia Sweden Switzerland Trinidad and Tobago Turks and Caicos Islands United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States of America American Virgin Islands Students entering the United States for the first time in New Jersey or transferring to a New Jersey School coming from ANY Country that is NOT listed above, have to be tested for IGRA or Mantoux Tuberculosis, unless they have an exception. Rev. 07/22/ WEST NEW YORK PUBLIC SCHOOLS Physical Examination for Student Health Appraisal [PART 1 of 2] TO BE COMPLETED BY THE PHYSICIAN AND RETURNED TO THE SCHOOL NURSE WITHIN 15 DAYS THE EXAMINING PHYSICIAN IS RESPONSIBLE FOR INFORMING THE SCHOOL OF ANY HEALTH PROBLEMS, WHICH MAY HINDER THIS CHILD FROM FULL PARTICIPATION IN THE SCHOOL HEALTH AND PHYSICAL. Note: check mark indicates normal findings Name: Birth Date: Address: School: History of Immunizations: DTaP/DTP/ 1. Pneumoccal 1. I.P.V.: 1. Td: 2. Conjugate: (PCV ) HEP A: 1. M.M.R: Varicella: MANTOUX: Date given: Date Read: H.I.B: 1. Reaction: 2. X-ray: 3. Quantitative Test Given: Results: 4. https://jbhnews.com/anabolic-steroids-why-the-bad-rep/30512/ : INH STARTED: HEP B: 1. DOSE: 2. DURATION: 3. COMPLETED: 4. Pre-K must have FLU Vaccine administered between Sept. 1 st & Dec. 31 st Date given: 11 YR. Olds must have: Tdap: MENINGOCOCCAL: CONJUGATE (MCV 4) Recommended for ages 9 & older: H.P.V: Rotavirus: OTHER: Laboratory Findings: Hgb/Hct.: Urinalysis: Other: Does this child take any medication? Yes No Please indicate name of the medication and if it is to be given in school: Is there a history of any serious injuries, accidents or operations? Yes No Is there any impairment, disease or illness, past or present, of which the school should be informed, and to which special consideration should be given? Yes No Please indicate feedings, procedures, etc. Is the child under the care of a specialist? Yes No If yes, who and why? General condition: Print Doctor s Name Signature Date Health Care Provider s Stamp WEST NEW YORK PUBLIC SCHOOLS Physical Examination for Student Health Appraisal [PART 2 of 2] STUDENT S NAME: Height: Ears: Dermatitis: Weight: Blood Pressure: Hearing loss: Rt. Head / Neck: Tonsils: Lt. Nutrition: Lungs: Pulse: Glands: Allergies: Eye/Schlera/Pupils: Teeth: Anaphylaxis: Vision without glasses: Rt. Lt. Vision correction with Glasses/Contacts: Rt. Lt. Gumdia: Nose: Speech: Genitalia: Glands: (specify) Seizures: Abdomen: Stomach: Hernia: Orthopedic: Scoliosis: Structural: Feet: Asthma: Yes No Medication: Inhaler: Nebulizer: Dosage: Frequency: No Medication: Physical Education: Comments: Heart Rhythm: Murmur Yes No Diagnosis: Developmental Assessment: Fine/Gross Motor: Language Development: Autism Spectrum: Yes No Down s Syndrome: Yes No 1. Full activity recommended: 2. No competitive or contact sports: 3. Limited activity prescribed as follows: 4. Exclusion because: 5. Restricted (dates) from: to: HISTORY OF COMMUNICABLE DISEASES DIPHTHERIA: MEASLES: GERMAN MEASLES: MUMPS: SCARLET FEVER: WHOOPING COUGH: INF. _ LETTER DAY OF BLANCO-EUROPEO/NORTEAFRICAN/NEGRO/NATIVE AFFROAMERICAN NATIVE AFFAIRS OF HAWÁI/ISLEÑO OF THE AMERICAN/NATIVE INDIFIC OF ALASKA ASIÁTICO-CHINA/INDIA/JAPAN/COREA/FILIPINAS DIRECCION Apt. # THE CITY HOUSE West New York Stated New Jersey COUNTRIES (SI U.S.A., CIUDY AND STATE INDICAR FAVOR) CODIGO POSTAL Student Health Insurance Name APPLICATION TO THE UNITED STATES THE LAST SHIPPING TO THE SESSION (SCORE AND STATE) I only said that I was able to report the PADRE RESPONSIBLE BY THE STUDENT IF I DON'T GO WITH THE STUDENT IF I DON'T GET A RESTRICTION OF THE COURT IF I DON'T APPELLATE TO PLAY SCITED NACENCE OF U.S.A. THE CASE NUMBER AND DIRECTION OF THE EMPLEMENTATION OF THE TELEPHEN EMPLEMENTATION OF THE CELULAR CELL ELECTRONIC INFORMATION OF THE MADRE RESPONSIBLE BY THE STUDENT IF I DON'T GO WITH THE STUDENT IF NOT A RESTRICTION OF THE COURT IF NOT APPEARCH THE CASE APPOINTMENT AND DIRECTION OF THE EMPLEMENTATION OF THE TELEPHONE OF THE NUMBER OF THE CELULAR CELL ELECTRONIC INFORMATION OF THE GUARDIAN RESPONSIBLE BY THE STUDENT IF I DON'T GO WITH THE STUDENT IF NOT A RESTRICTION OF THE COURT TELEND OF THE NUMBER CASE AND DIRECTION OF THE EMPLEMENTATION OF THE NUMBER OF THE CELULAR ELECTRONIC CORREO EMERGENCY CONTACTS NOT TO BE PADRE/GUARDIAN NUMBER OF EMERGENCY CONTACT 1. DIRECTION TELEPHEN RELATION OF THE NUMBER HOUSE OF THE CELULAR NAME OF CONTACTS OF EMERGENCE 2. DIRECTION TELEPHEN RELATION OF THE NUMBER HOUSE OF THE CELL INFORMATION ON HERMANS/AS (STUDING IN WEST NEW YORK'S HEATS) NUMBER OF CHILDREN IN THE FAMILY SHOULD SCREEN GROUND NOBODY SHOULD SHOW SHOULD SHOULD SHOW
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