PARENTS/GUARDIANS: Please ensure that you provide all of the following documents with the
submission of your application. These documents are required to complete the enrollment of your
scholar. Please check off each document and provide your signature at the bottom of the page.
☐
Report Card
☐
Transcript
☐
Birth certificate
o Application for birth certificate unacceptable
☐
Official TN Certificate of Immunization
o Must be state of TN
o No blue cards
o Must be signed/stamped by physician
☐
Legal Documents
o Court Order for Name Changes
o Affidavit of Student Guardianship
☐
Two Proofs of Residency (dated within 60 days of enrollment date)
o Acceptable Proofs of Residency
§ Shared residency affidavit
§ Homeless affidavit
§ Utility bill
§ Housing/rental, lease agreement, purchase contract, mortgage statement,
deed or property tax statement, Homeowner’s or renter’s insurance
statement
§ Automobile insurance/ Automobile registration
§ Health insurance statement/card
§ Payroll statement
§ Proof of public assistance
o Unacceptable Documents
§ Driver’s License
§ Bank statements
§ Departmental store statements
☐
TN Migrant Occupational Survey (Attached)
☐
Home Language Survey (Attached)
☐
Household Information Survey (Attached)
________________________________________________
Parent/Guardian Signature
____________
Date
________________________________________________
GRAD Admin Signature
____________
Date
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
1
GRAD Academies, a division of Project GRAD USA, are New Tech Network High Schools, which anchor
student learning in a project based, technology enriched curriculum. Teachers act as coaches, guides, and
facilitators and to lead students to build authentic and meaningful projects tied to state and national
Common Core Standards.
ABOUT GRAD ACADEMY MEMPHIS
The mission of GRAD Academy Memphis is to provide all students in an open-enrollment high school with
an outstanding 21st century education, to prepare them for college and career success, and to inspire
them to be engaged participants in our democracy.
It is the first GRAD Academy High School in the nation, and employs a new design that joins the highly
successful New Tech Network (NTN) high school learning and development platform with the proven,
comprehensive wraparound supports and college readiness strategies of Project GRAD USA (GRAD) as
well as several high tech adaptive learning and data management support elements.
GRAD Academy Memphis is designed on a computer-integrated, project-based learning model, with a
STEAM (Science, Technology, Engineering, Arts, and Mathematics) curricular focus, complemented by an
aggressive focus on closing skill and achievement gaps, especially in literacy and mathematics. Students
work in teams and focus on real-world problems.
ENROLLMENT GUIDELINES & REQUIREMENTS
GRAD Academy Memphis is an open enrollment high school that is part of the Achievement School District
(ASD) of Tennessee, an innovative statewide district that works to move the bottom five percent of schools
in Tennessee to the top twenty-five within five years. Our school is fully aligned with Tennessee and
national Common Core Standards.
Currently, all high school students grades 9 through 11are eligible for enrollment at GRAD Academy
Memphis
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
2
STUDENT ENROLLMENT FORM
SECTION 1: STUDENT INFORMATION (please print)
__________________________________
First name
________
M.I.
___________________________________
Last name
____________________________________________________________________________________
Street Address
__________________________________
City
________
State
___________________________________
Zip code
__________________________________
Date of Birth (mm/dd/year)
________
Age
____________________________________
Gender (Male, Female)
African American/Caucasian/Hispanic/Asian/Other: ____________
Race (Circle One)
(specify)
__________________________________
Current Grade
_______________________
Social Security Number
______________________________________________
Current School
Allergies or Dietary Restrictions (please list all): _____________________________________________
____________________________________________________________________________________
SECTION II: PARENT/GUARDIAN INFORMATION (please print)
PARENT/GUARDIAN # 1
__________________________________
First name
________
M.I.
___________________________________
Last name
____________________________________________________________________________________
Street Address
__________________________________
City
_____________________________________
Phone (primary # or preferred contact #)
________
State
___________________________________
Zip code
__________________________________________
Email
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
3
PARENT/GUARDIAN #2
__________________________________
First name
________
M.I.
___________________________________
Last name
____________________________________________________________________________________
Street Address
__________________________________
City
_____________________________________
Phone (primary # or preferred contact #)
________
State
__________________________________
Zip code
_________________________________________
Email
SECTION III: BACKGROUND INFORMATION
Has your child ever received or is currently receiving 504 or IEP Services? Circle One: YES / NO
If yes please explain: __________________________________________________________________
____________________________________________________________________________________
Does your child reside with the parents/guardians named on this enrollment form?
_______ Yes
________ No
If no, please clarify: _______________________________________
___________________________________________________________________________________
Do you have other children who will be entering high school within the next four years?
________ Yes _________ No
How did you hear about GRAD Academy Memphis?
____ Friend or colleague
____ GRAD Academy Memphis website
____ Internet or social media - Please list: _________________________________________________
____ Current Scholar and/or Parent - Please name: _________________________________________
____ GRAD Academy Memphis Faculty Member - Please name: _______________________________
____ Print/radio/television advertisement
____ Public or community event
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
4
SECTION IV: HEALTH INFORMATION
Does your child have a medical condition that may affect his or her school day?
_________ YES
__________ NO
If YES, please describe here:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Allergies
Type of Allergy (please mark all that may apply)
___ Food
List Foods: _________________________________________________________
___ Medications
___ Bee Sting
___ Other
List Medications: ____________________________________________________
List:_______________________________________________________________
Allergic Reactions (please mark all that may apply)
___ Coughing
___ Generalized swelling
___Wheezing
___ Rash
___ Local swelling
___ Nausea
___ Difficulty Breathing
___ Hives
___ Other
List: ______________________________________________________
Current Medications (please list all)
____________________________________________________________________________________
____________________________________________________________________________________
Food Restrictions (please list all that may apply or indicate none by writing N/A)
Due to Gastrointestinal Intolerance ____________________________________________________
Due to Religious Reasons ___________________________________________________________
Immunizations
Are all of the immunizations for your GRAD Academy Scholar up to date for the upcoming school year?
_________ YES
__________ NO
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
5
Health Insurance Information
Name Name of Insured:
Name Name of Insurer:
Insurer Insurer’s Phone Number:
Insurer Insurer’s Address
List 3 Emergency Contacts
(1) Name: ____________________________________
Phone: ______________________________
(2) Name: ____________________________________
Phone: ______________________________
(3) Name: ____________________________________
Phone: ______________________________
By signing below, you indicate that all information included on this student enrollment form for GRAD
Academy Memphis is accurate and specified to the best of your knowledge.
___________________________________________________________________________________
PARENT/GUARDIAN SIGNATURE
____________________________________
DATE
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
6
INSTRUCTIONS FOR SUBMITTING ENROLLMENT FORM
IN PERSON OR BY MAIL:
GRAD Academy Memphis
Attn: Admissions & Enrollment
1880 Prospect St. | Memphis, TN 38106
VIA FAX:
(901) 881-1155
VIA EMAIL:
[email protected]
QUESTIONS?
For more information or for questions regarding student enrollment at GRAD Academy Memphis, please
contact the school office at (901) 206-8848 or email [email protected]
NON-DISCRIMINATION NOTICE
Enrollment will not be denied to any eligible applicant based on the basis of sex, race, religion, national
origin, ancestry, pregnancy, marital or parental status, sexual orientation, or physical, mental, emotional
or learning disability. The School will not discriminate in its pupil admissions policies or practices whether
on the basis of intellectual or athletic ability, measures of achievement or aptitude, or any other basis
that would be illegal if used by any public school.
FOR OFFICE USE ONLY
Date Received: ____________________________________
Delivery Method: ________ Mail
_______ Email
Received by: ______________________________________________
Time Received: ______________________________________
_______ Fax
_______ In person
Eligible for Enrollment: __________________________
Notes:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
7
Please Indicate Your Scholar’s Uniform Sizes Below:
Boys/Mens Pleated Pants Sizes: ☐Boys 14 ☐Boys ☐16 Boys ☐18 Mens ☐27 Mens ☐28
☐Mens 29 ☐Mens 30 ☐Mens 32 ☐Mens 34 ☐Mens 36 ☐Mens 38 ☐Mens 40
Boys/Mens Oxford shirt sizes: ☐Boys 14 ☐Boys 16 ☐Boys 18 ☐Adult Small ☐Adult Medium
☐Adult Large ☐Adult Extra Large ☐Adult XXL ☐Adult XXXL
Unisex School Vest Sizes: ☐Youth Medium ☐Youth Large ☐Adult small ☐Adult Medium
☐ Adult Large ☐Adult Extra Large ☐Adult XXL ☐Adult XXXL
Unisex School Cardigan sizes: ☐Youth Medium ☐Youth Large ☐Adult small ☐Adult Medium
☐ Adult Large ☐Adult Extra Large ☐Adult XXL ☐Adult XXXL
Grey Girls/Juniors Skirt Sizes: ☐Girls ☐10 ☐Girls 12 ☐Girls 14 ☐Girls 16 ☐Juniors 28
☐Juniors 30 ☐Juniors 32 ☐Juniors 34 ☐Juniors 36 ☐Juniors 38 ☐Juniors 40 ☐Juniors 42
Plaid Girls/Juniors Skirt Sizes: : ☐Girls ☐10 ☐Girls 12 ☐Girls 14 ☐Girls 16 ☐Juniors 28
☐Juniors 30 ☐Juniors 32 ☐Juniors 34 ☐Juniors 36 ☐Juniors 38 ☐Juniors 40 ☐Juniors 42
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
8
HOME LANGUAGE
SURVEY
STUDENT
NAME
DATE
GRAD ACADEMY MEMPHIS
CAMPUS
1. What is the first language this child learned to speak?
__________________________________________________________________
2. What language does this child speak most often outside of school?
__________________________________________________________________
3. What Language do people usually speak in the child’s home?
__________________________________________________________________
4. Where was this child born?
__________________________________________________________________
5. What date did the student enter the U.S.?
__________________________________________________________________
6. If the student attended another U.S. school, what date did he or she start?
__________________________________________________________________
Parent Signature__________________________________
All student information collected by GRAD Academy Memphis will be handled and protected following the
guidelines set forward in the Federal Educational Rights and Privacy Act (FERPA).
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
9
Household Information Survey 2015-16 School Year
PLEASE EDIT: DISTRICT / SCHOOL INFORMATION
Parent Name:
Street Address:
City:
State:
Student's Legal Name
(As on Birth Certificate)
Student
ID
Date of Birth
Zip:
School Name
Grade
1.
2.
3.
4.
5.
6.
7.
8.
Number in Household
(Fill in the blank)
Please check the box below that represents your Annual Gross Income:
☐ Less than $21,775
☐ Between $21,775 and $29,471
☐ Between $67,951 and $75,647
☐ Between $29,471 and $37,167
☐ Between $75,647 and $83,343
☐ Between $37,167 and $44,863
☐ Between $83,343 and $91,039
☐ Between $44,863 and $52,559
☐ Between $91,039 and $98,735
☐ Between $52,559 and $60,255
☐ Between $98,735 and $106,431
☐ Between $60,255 and $67,951
Signature: An adult household member must sign the application.
☐ Over $106,431
I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will receive
federal funding and state funding based on the information provided.
Sign here:
Date:
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
10
ENGLISH
Migrant Education Program
Occupational Survey
STATE OF TENNESSEE
DEPARTMENT OF EDUCATION
BILL HASLAM
GOVERNOR
KEVIN HUFFMAN
COMMISSIONER
th
6 FLOOR, ANDREW JOHNSON TOW ER
710 JAMES ROBERTSON PARKW AY
NASHVILLE, TN 37243-0375
Student Information
Last Name
District
First Name
School:
Gender
Grade
Race
Year
Migrant students may be eligible for additional services and assistance. Please answer the following questions
and return the survey to the school so that we can determine if your child qualifies for migrant services.
1. Did you or someone in your family come to Tennessee looking for temporary or seasonal work in
agriculture, fishing, dairy, or in any plant processing foods (examples: working with tobacco,
tomatoes, cotton, strawberries, nurseries, trees, pork, chickens, vegetables, etc)?
YES
NO
If yes, please mark which member of the family does or did this kind of work:
Mother
Father
Children
Other
2. Do you or someone in your family currently work in agriculture fishing, dairy, or in any plant
processing foods (examples: working with tobacco tomatoes, cotton, strawberries, nurseries, trees,
pork, chicken, vegetables, etc).
YES
NO
If yes, please mark which member of the family does this kind of work:
Mother
Father
Children
Other
3. If your current job is not temporary work in agriculture or fishing, did you or someone in your
family work in a temporary or seasonal agriculture of fishing in the last 3 years?
YES ______
If yes, where?
NO________
______________________________________________
State
Country
City
If you answered “yes” to any of the questions above, please answer questions 4, 5 and 6.
4. How long have you been in this county?
months
years
5. What is your current address?
6. What is your current telephone number?
NOTE TO THE LEA: PLEASE RETURN ONLY SURVEYS WITH ONE OR MORE “YES ” RESPONSES TO JESSICA CASTANEDA 4660
HILLS CREEK ROAD, MCMINNVILLE TN 37110 CALL 931-668-4139 IF YOU HAVE QUESTIONS.
Graduation Really Achieves Dreams
GRAD Academy Memphis | 1880 Prospect St. | Memphis, TN 38106 | 901-206-8848 |Fax: 901-881-1155|
www.gradacademymemphis.org
11
TM
Memphis
Non-Clinic
High School
(Modified Packet - reduced by three pages)
Every child needs the opportunity for healthy development.
Through its partnership with Well Child, your school district brings health care to the schools. Well
Child has performed preventative health exams in schools for over 10 years and has helped parents
identify many hidden health issues that needed medical attention.
This packet includes consent forms for two types of exams:
 A Physical Health Exam and
 A Comprehensive Vision Exam.
Well Child is committed to improving the health of children and tens of thousands of parents have
taken advantage of these services. Well Child is able to bill to the following insurance carriers: United
Health Care Community Plan, Tenn-Care Select, BlueCare, CoverKids, Amerigroup, Cigna, and
Aetna. These services are at no cost to you, to the school or to the district.
You will be made aware of all findings and given information about any recommendation for your child
to have further health evaluation.
Please complete the following forms (including signing the consents) and return to the school.
A community’s highest commitment is to the health and education of
its children. If we do not do both we will not accomplish either.
Journal of School Health
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
CONSENT/REGISTRATION FORM
It is very important that you complete every question
Name of School _______________________ Grade ____ Section ____ Teacher _____________
CHILD’S NAME – PLEASE PRINT
Last Name,
CHILD’S SOCIAL SECURITY NUMBER
First Name
M.I.
ADDRESS
CITY
SEX  Male
RACE: Black or African Amer.
White
Hispanic
Asian
Other
STATE
ZIP CODE
 Female
AGE __________
DATE OF BIRTH
(mm/dd/yyyy)
/
/
NAME OF CHILD’S DOCTOR OR CLINIC ______________________________________________
Name of Insurance Carrier (Please circle one): UnitedHealthCare, Tenn-Care Select, BlueCare, Amerigroup
Tenn-Care Member ID:__________________ CoverKids, Cigna, Aetna, No Insurance, Other:_____________
Well Child will bill your insurance carrier or managed care organization for this physical exam
Private Insurance: Carrier: ________________ Policy #: _________________ Group#: ______________
Policy Holder:
Name: ______________________ Birth Date:_____________________
PARENT OR GUARDIAN’S INFORMATION
RESPONSIBLE PARTY’S NAME:
HOME PHONE NUMBER
(
) __ __ __ - __ __ __ __
RELATIONSHIP TO CHILD
WORK PHONE NUMBER
*CELL NUMBER
(
)__ __ __ - __ __ __ __ (
)__ __ __ - __ __ __ __
E-MAIL ADDRESS: _______________________________________ To receive child’s exam result.
PRIMARY LANGUAGE SPOKEN AT HOME ___________________________
FRIEND OR RELATIVE WHO WE CAN CONTACT IN CASE OF EMERGENCY AND SHARE MEDICAL INFORMATION
NAME________________________RELATIONSHIP_______________PHONE (_____)_______________
NAME________________________RELATIONSHIP_______________PHONE (_____)_______________
A Well Child exam is the same as in most doctor’s offices and includes the following procedures:
1. Listen to the heart and lungs; 2. Feel and listen to the stomach; 3. Check the back for scoliosis (curve of the spine);
4. Examine the skin for problems such as rashes or infections
5. Assess stages of development through observation
Decline this item (#5) only.
A Board Certified Provider will conduct the Well Child exam behind a privacy screen. During the exam, clothes will be
lifted but not removed.
PARENTAL/GUARDIAN CONSENT AND ACKNOWLEGMENT: Notice of Privacy Practices is available at: www.wellchild.com
I authorized my child to receive the annual physical exam conducted by Well Child, to be completed during the
upcoming school year. I have been notified of Well Child’s privacy practices. I authorize Well Child to send
screening results home with my child in a sealed envelope, to release information to my insurance carrier in
order to process payment claims and to receive payment of medical benefits for services rendered. For
purposes of treatment and referral, I authorized release of medical information to the Health Department, the
school system and my child’s physician/primary care provider. I give permission to the school district to release
my child’s immunization (shot) record for review by Well Child.
*Date:
*Parent/Guardian Signature X
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
HISTORY
Child’s Name: ______________________________________ SSN: ________________________
1.
2.
3.
Current Medicines:
List Over-the-counter & Prescription medicine:
Current Treatment: Please check below any service your child is currently receiving:
Development (motor skills/learning):
Speech/Language:
Vision (glasses or contacts):
Answer Yes with an ☑
Exercise / Elimination:
Does your child eat meat?
Is your child's appetite?
Good:
Average:
Picky:
Child’s bowel movements:
Normal:
Diarrhea:
# days_____
Hard:
How many days a week does your child exercise more than 30 minutes?
0–3 days:
4.
Child’s Health History
Acne/Skin Problem
ADHD/ADD
Anemia
Asthma
Autism
Bleeding- Type:
Bronchitis
Has your child ever had any of the following? Answer Yes with an ☑
Cancer- Type:
Heart murmur
PE tubes in ears
Chicken Pox
Liver trouble
Seizures
Diabetes/sugar
Mumps
Sickle cell tested
Ear infections
Navel Hernia
Sickle cell Trait
Eczema
Passed out with
Sickle cell Disease
exercise:
Headaches
Sinus congestion
Thyroid problems
5.
GIRLS:
6.
Surgeries or Hospitalizations? Answer Yes with an ☑:
7.
Started Period: Month_________ Year___________
Allergies: Answer Yes with an ☑:
Medicines
Amoxicillin
Penicillin
Food
Peanuts
Shellfish
Environment
Dirt/Dust
Grass/Pollen
Immunizations (shots) up to date?
9.
Developmental History: Answer Yes with an ☑:
Did your child have any delays in:
i. Learning
Was this child a premature birth?
11
Yes:
Heavy Bleeding?
If yes, explain and give dates:
Other: ____________________
Other: ____________________
Other: ____________________
8.
10
# days____
4 days+:
No:
Do Not Know:
ii. Walking
iii. Talking
None to all Medical Problems listed below?:
Family History: Answer Yes with an ☑:
Asthma/Lung disease
High blood pressure
Mental illness
Diabetes/Sugar
High cholesterol
Stroke
Heart Trouble:
Liver disease
Sickle Cell:
Social/Socioeconomic History
Number of children at home?
Does child wear a seat belt?
Answer Yes with an ☑
Anyone smoke in the home?
Are you a single parent?
A working smoke alarm?
Child have problems in school?
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
RISK ASSESSMENT QUESTIONNAIRE
Child’s Name: _________________________________________________________
Tuberculosis:
A YES or UNSURE answer may result in a referral to see your PCP or the Health
Department for further testing.
1
Has your child been in close contact with a person with infectious tuberculosis?
2
Does your child have HIV infection or considered at risk for HIV Infection?
3
Does your child have contact with the any of the following: HIV infected, homeless,
nursing home, institutionalized individuals, illicit drug users, or migrant farm workers?
4
Does your child have a poor immune system due to disease or treatment of disease?
5
Was your child born in Asia, Africa or Latin America, a refugee, or an immigrant?
6
Did your child have an abnormal skin reaction (redness/swelling) to a TB skin test?
7
Has your child had TB?
Yes
No
Not
sure
PEDIATRIC SYMPTOM CHECKLIST 17 (PSC-17)
Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child’s
behavior, emotions, or learning, you can help your child get the best care possible by answering the following questions. Please
indicate which statement best describes your child.
Please mark under the heading that best describes your child:
Never
(0)
1
Fidgety, unable to sit still
2
Feels sad, unhappy
3
Daydreams too much
4
Refuses to share
5
Does not understand other people’s feelings
6
Feels hopeless
7
Has trouble concentrating
8
Fights with other children
9
Is down on him or herself
10
Blames others for his/her troubles
11
Seems to be having less fun
12
Does not listen to rules
13
Acts as if driven by a motor
14
Teases others
15
Worries a lot
16
Takes things that do not belong to him/her
17
Distracted easily
Sometime
(1)
Often
(2)
Totals
Comments:
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
Middle and High School Student's Personal History
Please explain "Yes" answers below.
Student Name: ____________________________________________
Yes
1
2
3
4.
5
6
7
8
9
10
11
12
13
No
Has your child ever passed out during exercise?
Has your child ever been dizzy during or after exercise?
Has your child ever had chest pain during exercise?
Does your child tire more quickly than his/her friends during exercise?
Has your child ever had a head injury?
Has your child ever been knocked unconscious?
Has your child ever had a stinger, burner or pinched nerve?
Has your child ever had heat or muscle cramps?
Has your child ever been dizzy or passed out in the heat?
Does your child have trouble breathing or coughing during or after activities?
Does your child use any special equipment ( braces, neck role, eye guard)?
Has any immediate family member died from unexplained causes before they
were 50 years old?
14
Has your child used an asthma inhaler anytime during the past year
Has your child ever sprained/ strained, dislocated, fractured, broken or had
repeated swelling of any bones or joints?
15
Please explain any of the above “yes” answers here
FEMALES ONLY: What was the longest time between your child's periods during the past year?
_________
ATTENTION PARENTS:
If you want this exam to be a SPORTS PHYSICAL,
please complete these questions:
If your child has a history of ASTHMA:
1
2
3
4.
Yes
No
Has your child been to the hospital or emergency room with an asthma
attack within the past six (6) months?
Does your child use an inhaler for wheezing at times?
If yes, how often does your child need to use the inhaler because of wheezing?
_______ times per week _______ times per month _______ times per year
When was the last time your child wheezed and used an inhaler? __________________
If your child has had to visit the Emergency Room or Hospital within the past six
months for Asthma, or has used an emergency inhaler within the past month, STOP!
Your child will need to see his/her usual PCP to be cleared to play sports
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
WELL CHILD
Health Services Survey
Dear Parent/Guardian:
PLEASE COMPLETE ONLY IF YOUR CHILD HAD WELL CHILD HEALTH EXAM LAST YEAR
SURVEY QUESTIONS
Yes
1.
Last year, did your child bring home the yellow envelope containing
exam results?
2.
Are you satisfied with the services you received from Well Child?
3.
Have you seen improvements in your child after using Well Child’s
services?
If 3 is "Yes", in what areas did you see improvements?
____ Attendance ____ Achievement ____ Behavior
____ Health
4.
Would you like to share a story about your child’s Well Child exam?
5.
Is there any change or improvement you can suggest for the Well Child
exam?
No
Don’t
Know
Other ___________
If 5 is “Yes”, please explain how we can improve our service:
6.
What is the most valuable thing you have gained from your child’s participation in the Well Child
annual health exam?
7.
Are you aware of the optometry services available in the school?
8.
Are you aware of the SCS Regional school-based clinics?
9.
Would you be in favor of having in-school dentistry available?
Thank you for taking the time to complete this important survey. We value our relationship with our families
and look forward to continuing to serve your child or children in the future.
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
ADOLESCENT HEALTH SERVICES
Dear Parent/Guardian:
You may be familiar with Well Child as a provider of screening physicals and sports’ physicals performed at
your child’s school. You may also be aware that Well Child operates the four SCS Regional Health Clinics,
located at East High, Northside High, Sheffield Career and Technology Center, and Westwood High. Services
provided at these clinics include physicals, immunizations and optometry services.
Well Child now offers adolescent health services for high school students.
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These services are provided by certified physicians and nurse practitioners.
The providers educate the students using the Family Life Curriculum of Shelby County Schools.
Abstinence is stressed and encouraged, and the students are also educated on other ways to protect
themselves from pregnancy and STDs.
The providers offer the opportunity for students to have a private appointment at one of the SCS
Regional Health Clinics to address any questions or problems they may have.
Confidential services provided at the clinic appointment may include gynecologic exams when
necessary, lab work, and dispensing/prescribing medication.
With your permission, Well Child can provide these services to your high school child.
If you would like your student to receive these services, please complete and return the bottom portion of this
form.
For more information or to schedule to bring your child to the clinic yourself, please call 901-531-6321.
I give permission for Well Child to provide adolescent health education to my child and transport him/her to the
SCS Regional Health Clinics for the purpose of an adolescent health visit. I authorize my child’s information to
be released to his/her insurance company to process payment claims and to receive payment of medical benefits
for services rendered.
Student’s name: _______________________
Date of Birth: ________________________
Social security number: ________________
Insurance company: ___________________
Insurance policy number: ________________
Insurance group number: _______________
Parent/Guardian signature: X__________________________
Date: ___________________
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
Well Child provides eye services and eyeglasses to students in the schools.
If your child needs vision services, or has failed their school vision screening, he/she is eligible
to receive an eye exam or renew his/her prescription for glasses. The exams are performed by a
licensed optometrist, are billed to insurance and have no out of pocket expense to you.
If glasses are required, a Well Child optician will go to the school and fit your child with the
corrective lenses and frames about two or three weeks following the vision exam.
Child’s first name: ________________
Child’s last name: _________________________
Date of Birth:________________ School name:______________________________________
Phone number:_______-_______-_________
AUTHORIZATION FOR VISION ASSESSMENT AND TREATMENT
I authorize the performance of optometry examinations, treatments, and/or referrals by Well Child
staff doctors. I acknowledge that any information obtained from this examination may be used for
educational purposes, provided that individual identities, rights and liberties will be protected. I
further grant permission to release information to my insurance carrier in order to process payment
claims and for Well Child to receive payment of medical benefits for services rendered.
If you want this service for your child please complete the information below and the
following page of medical history.
 Pupil dilation is using eye drops to make the pupil larger to help the doctors examine the
inner eye health. Dilation can include some sensitivity to light and mild blurred vision for up
to 2 hours.
 To ensure my child’s eye health is normal:
___ I authorize pupil dilation
___ I will schedule pupil dilation at a later date
Parent/legal guardian sign here: X_____________________________ Date: ___________
Please call Well Child if you have questions or want to be present for the exam
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
EYE HEALTH AND MEDICAL HISTORY QUESTIONNAIRE
Child’s name:______________________________________________________
Is this your first eye exam?
Yes
No
Last eye exam date:_________ Doctor for last eye exam:_________________
CHILD EYE HEALTH HISTORY
CHILD MEDICAL HISTORY
Glaucoma
Yes
No
Sickle Cell
Yes
No
Cataracts
Yes
No
Weight change
Yes
No
Eye Injury
Yes
No
Diabetes
Yes
No
Retinal Disease
Yes
No
High blood pressure/Hypertension
Yes
No
Loss of vision/Blindness
Yes
No
Bronchitis
Yes
No
Eye turn/Strabismus
Yes
No
Sinus congestion
Yes
No
Lazy eye/Amblyopia
Yes
No
Asthma
Yes
No
Eye infection
Yes
No
Diarrhea/Constipation
Yes
No
Dry eye
Yes
No
Genital, Kidney, Bladder problems
Yes
No
Reading difficulty
Yes
No
Arthritis, joint/muscle pain
Yes
No
Blurred vision
Yes
No
Skin Problems
Yes
No
Double vision
Yes
No
Headaches, Migraine, seizures
Yes
No
Eye Redness
Yes
No
Mental / Emotional problems
Yes
No
Eye Itching
Yes
No
Thyroid/Other Gland problems
Yes
No
Feels like something is in the eye
Yes
No
Anemia, bleeding problems
Yes
No
Excess watering and tearing
Yes
No
Diabetes
Yes
No
Stye or Chalazion
Yes
No
Other:
Tired eye
Yes
No
FAMILY EYE AND MEDICAL HISTORY
Not sure
Glared or light sensitivity
Yes
No
Glaucoma
Yes
No
Not sure
Flashes/ floaters in vision
Yes
No
Cataracts
Yes
No
Not sure
Eye pain
Yes
No
Retinal disease
Yes
No
Not sure
Does your child wear Glasses?
Yes
No
Loss of vision/Blindness
Yes
No
Not sure
If yes, how old is your current pair?
Eye turn/Strabismus
Yes
No
Not sure
Months:________________
Years:___________
Lazy eye/Amblyopia
Yes
No
Not sure
MEDICATION: List all medications including over-theHigh blood
Yes
No
counter
pressure/Hypertension
Not sure
Diabetes
Yes
No
CHILD DEVELOPMENTAL HISTORY
Not sure
Was your child born early?
Yes
No
Not sure
Did the mother or the baby have difficulties and/or problems during pregnancy or birth?
Yes
No
If yes explain:
Did your child have any delays (sitting, walking, talking…)?
If yes explain:
Yes
No
Not sure
Does your child have any school difficulties? (reading, copying from board, etc.)
If yes explain:
Yes
No
Not sure
Is your child pregnant or nursing (for older students only)
CHILD ALLERGIES (does your child have any allergies?)
Allergies to medication
yes
No
If yes list:
Environmental/seasonal allergies
yes
No
If yes list:
Food or other allergies:
yes
No
If yes list:
Yes
No
Not sure
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
PLEASE DETACH THIS PAGE AND KEEP FOR YOUR RECORDS:
The exam includes the following:
1.
A comprehensive history, including developmental/behavioral screenings. Please complete
each enclosed form. If you need help with these forms, please call toll free 1-866-403-5858.
2.
Developmental Screenings. The Board Certified Provider will assess for normal
development of language, behavioral/emotional, memory, behavioral/emotional, perceptions
and motor functions.
3.
Vision and hearing screenings
4.
A complete head-to-toe physical exam (your child will remain clothed, but clothes will be
lifted during the exam – see page two for explanation).
5.
Immunization review. Parents must give signed consent for release of immunization record
(shot record) to be reviewed by Well Child staff. We will follow up with you if immunizations
are needed.
6.
Lab (blood work) is collected from a finger stick and lab will be completed only: (a) at the
ages shown below (b) when requested by parents/guardians (c) when medically necessary.
Hematocrit (Iron):
Six year olds, twelve year olds, menstruating females
and others when medically necessary
Lead:
Five year olds and younger when medically
necessary
Glucose or Hemoglobin A1C(Sugar): Children identified when medically necessary
Urine:
Children identified when medically necessary
This Well Child exam is the same as an annual visit to a pediatrician. Please be aware that
Private/Commercial insurances will pay for only one of these exams per year, so if you are seeing
your PCP, please continue to do so.
For information about Well Child’s Privacy Practices, please visit www.wellchild.com.
Contact us at 901-728-5858, or, 1-866-403-5858, if you would like to be present for the exam(s).
2/5/2014
© 2012 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.
Unauthorized reproduction of this material, in whole or in part, may result in immediate legal action.
.
COLE’S SCREEN
PRINTING
Cole’s Screen Printing is excited to be serving all your uniform needs. GRAD Academy Memphis boys will wear grey pants,
white oxford, vest, necktie and a blazer during the colder months. GRAD Academy Memphis girls will wear a grey or plaid
skirt, ¾ length oxford, a vest and a cardigan during the colder months.
PLAIN FRONT
OXFORD
$25
$ 22
PLEATED FRONT
¾ SLEEVE BLOUSE
SKIRT
$35
$ 22
$30
CONTACT US
901.340.6807
[email protected]
VISIT US @
7255 Winchester Road, 38125
UNISEX
VEST
$25
BLAZER
$60
UNISEX
PE SHIRT
$8
PE
SHORT
$8