archbishop rummel high school application for admission

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ARCHBISHOP RUMMEL HIGH SCHOOL Health information form 1901 Severn Ave. Metairie, LA 70001 Phone: 504.834.5592 To Be Completed by Parent or Guardian • Please Print or Type Date __________________________ Applicant’s Name_____________________________________________________________________________________________ Last First Middle Mailing Address______________________________________________________________________________________________ Street City State Zip Name(s) of brothers attending this school __________________________________________________________________________ Home Phone______________________ Father’s Name_____________________________________________________________Cell Phone _________________________ Employer _________________________________________________________ Work Phone ________________________ Mother’s Name____________________________________________________________ Cell Phone _________________________ Employer _________________________________________________________ Work Phone ________________________ If parents cannot be reached, call: ________________________________________________________________________ Phone _____________________________ Name / Relation Doctor __________________________________________________________________ Phone _____________________________ If, in a medical emergency, we are unable to contact you, do you consent to have your child transported to a hospital? Yes No Upon arrival, do you grant permission for the hospital and physician on call to treat your child? Yes No Please check the appropriate response: ( ) The school may NOT give my son medication of any kind. ( ) Upon his request, the school is authorized to give my son Tylenol. Please note any information concerning your son’s medical or physical condition that may affect his academic performance or physical activities at school, or that may be needed for prompt and effective care in the event of illness or emergency. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ My son is allergic to: ___________________________________________________________________________________________________________ _______________________________________________________________________________________________ continue to back
Check each item: Yes No Has your son ever had a head injury, heat stroke, heat exhaustion, or heat cramps? Has your son ever been unable to take physical education or participate in sports because of his health? Has your son ever had a serious injury or operation? Has your son used the services of a psychologist, psychiatrist, or other mental health personnel or clinic? If yes, give details ___________________________________________________________________________________________ __________________________________________________________________________________________________________ Has your son ever had the following: Check each item Yes No Check each item Yes No Check each item Yes No Check each item Yes No Allergies Mental disorder Ear disease Skin disease Anemia Pneumonia Epilepsy Thyroid trouble Arthritis Poliomyelitis Hay fever Tuberculosis Asthma Rheumatic fever Heart disease Ulcer Diabetes Rupture or hernia Liver disease Vertigo Meningitis Diphtheria Kidney disease Chicken Pox If yes, give details ____________________________________________________________________________________________ ___________________________________________________________________________________________________________ IMMUNIZATION INFORMATION FOR OFFICE USE ONLY: Records accompany this form Records to be forwarded. Parents are required by law to furnish the school with a valid, up-to-date copy of their son’s immunization record. Louisiana Statute 17:170 mandates that all students be properly immunized in order to attend any school within the state. The minimum immunization requirements for students to be eligible to attend and remain in school are: 4 DTP (Diphtheria / Tetanus / Pertussis combined) 3 Oral Polio 1 Measles / Mumps / Rubella The last DTP and Polio must have been given after the fourth birthday. It is recommended that a student be given a DT at 14 - 16 years of age and every 10 years after that. The law does allow for letters of dissent. However, no letter will be accepted except those signed by the parent or guardian at the school, in the presence of a school official. Check the appropriate response: ( ) My son has completed the immunizations require by state law. His next TD booster is due _________ to fulfill requirements. ( ) My son is still in the process of completing the immunizations require by state law. Number of doses needed to fulfill requirements: ________ DTP/TD _________ Polio _________ MMR Parent or Guardian Signature:_______________________________________________ Date: _______________________________ Print Name: _____________________________________________________________
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archbishop rummel high school application for admission

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