Florida School for the Deaf & the Blind Do More. Be More. Achieve More. Applications should be mailed or faxed to: Florida School for the Deaf and the Blind Rebecca Falbo, Deaf Department Principal 207 N San Marco Avenue St. Augustine, FL 32084 Fax: 904.827.2506 FSDB Expanded Core Curriculum (ECC) Summer Academy Application for Deaf/Hard of Hearing Students THIS ENTIRE FORM MUST BE COMPLETED AND RECEIVED BY FSDB BEFORE YOUR CHILD MAY BE ENROLLED. Student Information (to be completed by student or parent) Child s Name: Gender: Male Female Birth Date: / / Age (as of June 30, 2018): Height: Weight: Home Address (City, State, Zip): Name of Current School: Grade in August, 2018: Parent/Guardian Information Name of Parent/Legal Guardian: Relationship to Child: Home Address (if different from child ): Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Best Number to Contact You: Person to Contact in Case of Emergency Name of Emergency Contact: Relationship to Child: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Best number to contact you: Emergency Contact #2: Relationship to Child: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Best Number to Contact You:
PHYSICIAN S FORM THIS ENTIRE FORM MUST BE COMPLETED AND RECEIVED BY FSDB BEFORE YOUR CHILD MAY BE ENROLLED. Child s Name: Date of Birth: / / Address (City, State, Zip): Name of Parent/Legal Guardian: Relationship to Child: Address (if different from child): Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) VP: ( ) Email: This section must be filled out by a physician, PA or ARNP. A school physical form may be used. IMMUNIZATION HISTORY: Include all dates of basic immunizations and most recent boosters. (A vaccination history may be attached, but must include all information.) DPT 1 ST 2 ND 3 RD Tetanus Booster ORAL POLIO 1 ST 2 ND 3 RD Booster HEP B 1 ST 2 ND 3 RD Booster MEASLES VACCINE/MMR (LIVE) 1 ST 2 ND 3 RD PPD DATE (Optional) OTHER: DATE OTHER DATE OTHER PHYSICAL EXAMINATION Satisfactory Not Satisfactory Not Examined Details HEENT Mental Health Heart Lungs Abdomen Genitourinary Extremities Posture/Spine Metabolic Additional Health Information: Applicant is under the care of physician for the following conditions: Regularly Taken Medications: General Appraisal of Patient: Restrictions for camp: None Other: I HAVE EXAMINED THE PERSON HEREIN DESCRIBED AND REVIEWED THE HEALTH HISTORY. IT IS MY OPINION THAT THIS CHILD IS PHYSICALLY ABLE TO PARTICIPATE IN CAMP ACTIVITIES, EXCEPT AS NOTED ABOVE. Dr./PA/ARNP Name: Address: Phone: Practitioner Signature: Today s Date: Fax: Office Stamp
AUTHORIZATION FOR THE ADMINISTRATION OF PRESCRIPTION MEDICATION THIS FORM MUST BE COMPLETED BY A PHYSICIAN ASSISTANT, OR ARNP AND RECEIVED AT FSDB BEFORE YOUR CHILD MAY ATTEND. COPY FORM AS NEEDED TO LIST ALL PRESCRIPTIONS. Child s Name: Date of Birth: / / Address (City, State, Zip): Name of Parent/Legal Guardian: Relationship to Child: Address (if different from child ): Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) VP: ( ) Email: ---------------------------------------------------------------------------------------------------------------------------------------------------------------- KNOWN ALLERGIES: Prescribed Medication Dose Frequency Route Indication/ Condition Controlled? Y/N Side Effects Plan for Side Effects Authorization for Over-the-Counter Medications: Permission for the following over the counter medications to be administered to applicant if the medication is brought to camp with the appropriate labeling or permission for the following over-the-counter medications to be administered to applicant if deemed necessary by the camp medical staff. Please note that the name brand or its equivalent may be used. Dosages will be administered according to the directions on the original container unless a physician directs otherwise. If preferred, alternate over-the-counter medications may be sent with the child. All medications must be sent in the original containers with the dosage instructions provided and a signed order from a prescriber. PLEASE CROSS OUT ANY MEDICATIONS LISTED BELOW THAT IS NOT TO BE ADMINISTERED. Condition Treated Burns Chapped/Dry Lips Colds Cough Diarrhea Dry Eyes Emergency Allergy Eye Wash Headache Heat Rash Insect Bite Poison Ivy Rash Seasonal Allergies Skin Break Sore Throat Swimmer s Ear Toothache Upset Stomach Other Medication Used Burn, Gel, Burn Cream Chapstick, Vaseline Pseudoephedrine Guaifenesin syrup (e.g. Robitussin), cough drops Imodium, bismuth, subsalicylate Moisturizing eye drops, saline solution Dyphenhydromene Saline solution, eye wash Acetaminophen, Ibuprofen Medicated powder, cooling spray Medicaine, Afterbite, Afterbite Jr. Caladryl, Calagel, Calamine Lotion Hydrocortisone cream, Benadryl cream Pseudoephedrine, Benadryl Bacitracin, triple antibiotic cream/ointment, povidone, antiseptic, isopropyl alcohol, hydrogen peroxide Throat lozenges Swim Ear drops Orasol, Oragel, Anbesol Bismuth subsalicylate, antacid tablets Bug repellent, sunscreen AUTHORIZED PRESCRIBER MUST SIGN BELOW Prescriber Signature: Date: Prescriber Address: Prescriber Phone: ( ) Prescriber Fax: ( )
SOCIAL HISTORY Child s Name: Address (City, State, Zip): Date of Birth: / / Gender: Male Female Home Phone: ( ) Cell Phone: ( ) VP: ( ) Cause of Deafness: Hearing Loss: Right Ear Left Ear Hearing Aid/CI Model: Serial # Age hearing loss occurred: Child s primary mode of communication? Sign Oral Gestures PLEASE INCLUDE A COPY OF RECENT AUDIOLOGICAL REPORT. If the audiological report is not included with your application, it will not be processed! Does your child have any additional disabilities? If yes, please describe in detail: Does your child need assistance in: Toileting Eating Dressing Does your child wet the bed? Yes No Does your child sleepwalk? Yes No Often have nightmares? Yes No Been away from home before? Yes No Where? and for how long? Please comment regarding any other special needs your child may have:
FIELD TRIP, RELEASE OF INFORMATION, AND PICK UP PERMISSION Child s Name: Date of Birth: / / FIELD TRIPS A variety of field trips may be offered for Enrichment Program participants. All trips are approved by the Program Director; supervision and transportation are provided. Please indicate your permission for your child to participate in field trips by signing below: ***I grant permission for my child to take part in ECC Academy-sponsored field trips. RELEASE OF INFORMATION While your child is at FSDB, the School s Communication and Public Relations department may release to the public information about the ECC Academy participants and activities. School policy requires that only directory information may be released. Directory information includes: child s name, address, telephone number, date and place of birth, participation in activities and sports, dates of attendance, as well as pictures and video takes. Please indicate your permission for your child s information to be released by signing below. ***I grant permission for directory information about my child to be released to the public. CHILD PICK-UP NAME RELATIONSHIP TO CHILD PICK-UP HOW DID YOU HEAR ABOUT US? Internet Teacher DBS Newspaper School Counselor Other If other, please explain