Please return exam results to: INCA Head Start, PO Box 68, Tishomingo, Ok 73460 Office Use Only Date Entered on Child Plus ___/___/____
Date received by Health Manager_________
Parents: Head Start requires a physical exam, please return or fax this form when completed. (Head Start require un examen fisico, por favor regrese esta forma a Head Start cuando e doctor la complete.)
Child’s Name (Nombre):__________________________ Date of Birth (fecha de Nacimiento):_________ PHYSICIAN: Please complete the following three sections. 1—Mandatory Screenings: *Lead Test results:______ *HCT or HGB_______ Blood Pressure:____/____ Height:_______ Weight:______ 2—General Exam: Evaluation Normal Abnormal Evaluation Normal Abnormal Skin
Abdomen & Groin
Posture, Gait
Genitalia & Urinary
Speech, Communication Head
Bones, Joints
Eyes/Vision
Gross & Fine Motor
Ears/Hearing
Muscles
Nose
Cognitive
Mouth, Teeth
Self Help
Heart & Circulatory Chest & Lungs
Social Skills
Allergies
Neurological
Glands, Thyroid, Lymph Nutrition
3—Findings and Follow-up:
Normal Or Following conditions were discovered:________________________________________ _____________________________________________________________________________
1 sept. 2018 - Head Start is a full-day early childhood program for 3 &. 4 year olds. Applications are being taken for the 2018-. 2019 school year. Henrietta ...
diagnosis or treatment of my child. I authorize the release of all medical/dental pertinent information concerning my child to a representative of HEAD START.
approved, then to the Big Five Head Start Director or Assistant Director for approval or denial. • All meals will be coordinated with the school's child nutrition manager and cafeteria staff in order to provide meals to be taken on the field trip. •
Child's Name / Nombre de Nino: application for HEAD START for has been screened and the results are checked below: su aplicación de la HEAD START para ...
Student participation in Off-Season Conditioning Programs, at the school, is totally voluntary ... Open Facilities and Open Gym During the Regular School Term.
the parent/guardian. Yo, favor de imprimir ... I understand what the test, treatment or evaluation entails. ... The REASON for declining this service is stated below:.
Head Start Denial of Service Form. Negación de Servicios. I, print your name. , the parent/guardian. Yo, favor de imprimir su nombre el padre/guardián de.
The dates of your child's last physical and dental exam. • Other/Otro: Completion of registration will take between 1 and 1 ½ hours. Se tomara aproximadamente ...
Please describe your need for transportation (or why does your child need a ride to and/or from Head Start). Por favor describa su necesidad del transporte o por ...
PARTE 1 – HISTORIAL DE SALUD (debe ser completado por el padre/tutor legal antes del examen). Sí. No. El estudiante ha tenido: 1. □. □. ¿Una enfermedad ...
¿Dolor en el pecho, significativa o grave dificultad para respirar durante o después del ejercicio? 23. 24. □. □. □. □. ¿Usa anteojos o lentes de contacto?
28 ago. 2016 - High cholesterol D A heart infection D. Kawasaki disease. Other; - - - - - -. Has a doctor ever ordered a test for your heart? (For example,.
Name Change/Denomine el cambio: (must have legal papers). â¡. Change of Guardianship Name/Cambio de Guardián: **For Child Plus, enter as "other adult" ...
Height and Weight 3x/year. Cepillarse los dientes diariamente con fluoruro. Hemoglobin (si es necesario). Head Start documentación requerida: SI NO. Examen ...
1 may. 2018 - Additional documents may be requested by staff. Head Start provides ... Algunas partes de la solicitud deberán completarse en línea. (internet).
To be eligible to represent your school in any VHSL interscholastic athletic contest, you-. D must be a regular bona fide student in good standing of the school ...
sallos tuvieron fue la imperial ciudad del Cozco, que la ado- ... primer Inca Manco Cápac y por las innumerables victorias ... Fue la capital del Imperio inca.
Duck-walk, single leg hop .... I will not return to play in a game or practice until my symptoms have .... It's better to miss one game than the whole season.
las OPS, también llamado Evaluación médica de cualificación deportiva y ... sustituye a la asistencia médica completa y rutinaria del médico de cabecera del ...
