Check List - American Scholar Group · Check List SECTION I STUDENT APPLICATION – To be completed...

Check List

SECTION I STUDENT APPLICATION – To be completed by the student and parent

Personal Information Student’s Essay Parent’s Letter

SECTION II EDUCATIONAL INFORMATION

Transcript of Grades – To be signed and dated by School Administrator (Upload)(Upload prior 4 years of transcripts or academic reports from schools the student has attended) English Proficiency Evaluation – To be completed by English TeacherSocial Skills – To be signed and dated by English Teacher Skype Interview (To be scheduled with an American Scholar representative)

SECTION III

HEALTH QUESTIONNAIRE Medical History – To be completed by physician, parent and student Clinical Evaluation – To be completed by physician Immunization Record – To be completed by physician Authorization to Treat a Minor – To be signed by physician and parent

SECTION IV

INSERTS Program Agreement – To be signed and dated by parent and student Liability Release – To be signed and dated by parent and student Travel Authorization – To be signed and dated by parent and student School Request Form – To be signed by parent and student Copy of Passport (Upload)Copy of Bank Statement (Upload)Copy of I-20 if Transferring from another school in U.S. (Upload) Copy of Visa if available (Upload)

SECTION V SUPPLEMENTAL LETTERS OF RECOMMENDATION – At student discretion

Two letters of recommendation from teachers at student’s school (Upload)

SECTION VI STUDENT TEST RESULTS

Any relevant test score results (SLEP, TOEFL Junior, TOEFL/IELTS, ASG Scholarship Test, SSAT, SAT/ACT) (Upload)

STEPS REQUIRED TO COMPLETE THIS PACKET PLEASE BE SURE ALL DOCUMENTS ARE INCLUDED AND THAT THEY ARE ALL COMPLETE Please double check! Incomplete applications can not be processed.

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Representative: _______________________________ Country: _________________________________Applicant Name: _______________________________________ Male: Female: Nationality: _________________________________ Date of Birth: _____________________________ Grade Intend to Attend: _________________________________________________________________ If Student is transferring from an American school (Name of School): _____________________________

Please indicate two schools of choice for Fall or Spring attendance

Fall Spring Fall Spring


Fall Spring Fall Spring Fall Spring

Private Schools Living Word Christian School (K-12) Saint Nicholas School (K-8) Holy Family School (K-8) Saint Christine School (K-8) Saint Patrick School (K-8) Saint Charles School (K-8)Kennedy Catholic High School (9-12) Ursuline High School (9-12) Cardinal Mooney High School (9-12) John K. Kennedy High School (7-12)

Public Schools Greenville High School (7-12) Jamestown High School (7-12) Sharpsville High School (9-12)

To be filled out by American Scholar Group, Inc. Corporate Office

Accepted On: ______________________________ Rejected/Expelled: _____________________ I-20 Sent Out: ______________________________ Visa Approved: ________________________ Deposit Collected: __________________________ Full Payment Received: ____________________ Date Student expected to arrive: ________________________________________________________ Dorm (Greenville, PA): _____________________ Dorm (Struthers, OH): ____________________ Home Stay: ______________________________

Notes: ______________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________


Fall Spring Fall Spring Fall Spring Fall Spring

SECTION I: STUDENT APPLICATION

Page 1 of 4

Directions: Print neatly iIncomplete a

Family Name__________

Complete Mailing Addres

Telephone No._________

Date of Birth (Month)___

FATHER’S NAME:_____Address:__________________

_________________________

Date of Birth:_____________

Business phone:___________

Employed by:_____________

Occupation:_______________

MOTHER’S NAME:_____Address:_________________

_________________________

Date of Birth:_____________

Business phone:___________

Employed by:_____________

Occupation:_______________

Emergency Contact: (Phone n

BROTHERS and/or SISTE

Name:__________________________

Birthdate:_________________ Gende

Name:__________________________


Name:__________________________


Name:__________________________


Name:__________________________


PERSONAL INFORMATION

n black ink or type. Return all forms together making certain signatures and dates are included.pplications cannot be processed.

_________________ First Name____________________________ Middle Name________________________

s_________________________________________________________________________________________ Street Address City Country Zip Code

_______________ E-Mail ______________________________________ Fax No._____________________

____ (Day)________ (Year)_______ Passport No. (if known) _____________________________________

_______________________________ __________________________________

______ Country:____________________

___________ Speaks English________

___________________________________

___________________________________

__________________________________

___________________________________

___________________________________

______ Country:____________________

___________ Speaks English________

___________________________________

___________________________________

__________________________________

umber)___________________________

STUDENT PHOTO

RS

_________________________________________

r: ______ Living at home?:______

_________________________________________


_________________________________________


_________________________________________


_________________________________________


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Check any activity in which you are interested (check no more than six).

American Football Amusement parks Archery Arts and crafts Art/painting Backpacking Baseball Basketball Biking Bowling Camping Church activities Community work Computers

Cooking Dirt biking Family activities Fishing Golf Hiking History Hunting Ice hockey Martial arts Movies Museums Music Photography

Picnics Raising animals Racquetball Reading Riding horses Sailing/boating School activities Sewing Shopping Smoke shifting Snow Sports Soccer Swimming Table games

Tennis Theatre Track and field Travel Visiting relatives Walking Wall climbing Watching TV Water Skiing Woodworking Wrestling Writing Other: ________________

Please list any other specific interests, hobbies, and activities and any awards or commendations:___________________________________

_________________________________________________________________________________________________________________

Do you play in a band? Yes No

Do you play in an orchestra? Yes No

If yes, what instrument? ____________________________

Do you participate in any competitive sports? ______________________

How often do you attend church? _______________________________

Are you active in any church groups? ____________________________

List the chores for which you are responsible at home: _______________

___________________________________________________________

___________________________________________________________

Do you smoke? Yes No [For your information: the purchase and/or smoking of cigarettes for persons under age 18 is illegal in most parts of the USA. Individual living arrangements may involve additional rules which must be followed by the student.]

Are you allergic to animals? Yes No

If yes, what animals? _________________________________________

___________________________________________________________

If you are allergic, is your allergy controlled by medication? Yes No

Are you allergic to medications? Yes No

If yes, what medication? _______________________________________ How many years have you studied English? _______________________

STUDENT ESSAYPlease provide your reasons for wanting to enter the American Scholar Group, Inc. Private High School Program: (Attached written essay to this application if the given space below is limited)

_____________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Do you consume alcohol beverages? Yes No [For your information: the purchase and/or consumption of alcohol beverages for persons under age 21 is illegal in most parts of the USA.]

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PARENTS’ LETTER OF INTRODUCTION

Student’s Name ________________________________________________

Please type a letter in English in the space below directed to the American hosts with whom your son or daughter will live while in the United States. Describe your

child’s personality and interests, expectations and relationships. We ask that you be very frank and honest in your letter, and that you comment on your child’s

strengths and weaknesses. This will be very helpful to us in finding the best living arrangement for your child. Please limit your letter to this page.

Page 4 of 4

SECTION II: EDUCATIONAL INFORMATION

English Proficiency Evaluation

STUDENT’S NAME: ___________________________________________

The purpose of this form is to help us evaluate this student’s reading, writing, and verbal English language skills. It is crucial that your evaluation be as accurate as possible. Rating a student higher than his or her actual ability may result in serious problems for the student and the American school in which s/he is placed. We trust you will be conscientious during this interview and will complete our form carefully, accurately and honestly. Thank you.

READING: When asked to read aloud in English from a book, magazine, or newspaper, the student is able to: (check one only)

Excellent Read with few errors and can easily explain its meaning.

Good Read well except for very difficult terms and can explain most of the ideas.

Fair Read most of the vocabulary and explain the basic idea.

Poor Read and understand only the simplest words, and can explain little or none of the meaning.

WRITING: When asked to write a short essay in English stating what s/he hopes to gain from studying in America, the student: (check one only)

Excellent Writes fluently using lengthy sentences and abstract terms, with good English vocabulary and sentence structure.

Good May use irregular grammar, but uses a fair vocabulary in lengthy sentences.

Fair Writes only simple sentences with elementary vocabulary. Grammar is extremely irregular but is understandable.

Poor Uses very limited vocabulary and is difficult to understand.

VERBAL: Estimate the student’s ability to understand and speak English after engaging the student in English- only conversation about current events: (check one only)

Excellent Student is nearly fluent and can understand and respond to difficult questions including abstract terms. Will have no problem communicating upon arrival.

Good Student can understand most conversation. Responds slowly at times, but with appropriate answers. Is inquisitive and is able to pose necessary questions correctly.

Fair Student’s speaking ability is limited to a few basic words or phrases. Comprehension is limited. Student gets frustrated and easily reverts to his/her native language.

Poor Student can understand basic English but is translating. Makes mistakes but can be understood.

EVALUATION COMPLETED BY:___________________________________________________________

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Social Skills Evaluation

STUDENT’S NAME: __________________________________________

Excellent Very Good Good Fair Poor Inadequate

Ability to express oneself _______ _______ _______ _______ _______ _______

Emotional stability and maturity _______ _______ _______ _______ _______ _______

Self-reliance and independence _______ _______ _______ _______ _______ _______

Effectiveness with people _______ _______ _______ _______ _______ _______

General knowledge _______ _______ _______ _______ _______ _______

Impression s/he will make in U.S. _______ _______ _______ _______ _______ _______

Please briefly comment about this student’s motivation, reason for wanting to study in the United States, potential for success, study habits, and any other information you think will assist us in evaluating this individual.

English Teacher’s Name _________________________________________________________________________

Signature _____________________________________________________________________________________

School _______________________________________________________________________________________

Address ____________________________________________________ Tel. number _______________________

Date of Interview _____________________ Date of Evaluation ______________________

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PROGRAM AGREEMENT Please read carefully and sign and date where indicated.

In the City of ___________________, country of ______________________, on the __________ day of _____________________ in the year of 20___, I/we, the undersigned parents of _____________________________ my/our son/daughter, and I, the student applicant, agree to the following terms and conditions. The above-named student is applying to participate in a cultural and academic program sponsored by American Scholar Group, Inc. , and we give our son/daughter our permission to participate in this program.

1. We unde rstand the American Scholar Group , Inc . Stud y in Am erica program is designed to increase understanding among peopleof the wo rld and is not to be use d for the sole purpose of foreign language training. We have discussed the importance of goodbehavio r wit h our son/daught er and s/h e understand s the significan ce of acting in a mann er wh ich will reflect well on our familyand our country.

2. We understand and agree that the enrollment of our son/daughter in the exchange prog ram is primarily for cultural exchange andeducational enhancement but that a diploma or graduation is not guaranteed to any student. Success in the program is determinedby individual motivation and performan ce.

3. We unde rstand studen t placemen ts are based on compatib ility with American Scholar Group , Inc . residen tial facilitato rs and/orhost family.

4. Upon receipt of the asso ciate Am erican Scholar Group , Inc . handbook, we all agree to read and disc uss its contents. Should we notunderstand any part thereof, we will cont act our internationa l representativ e for clarification befo re the program participan t leavesour country. We understand that problems are to be res olv ed first by discussion s betwee n American Scholar Group , Inc . and yourfamily, inclu ding the program participant.

5. We agree that the program participan t will make every effo rt to adju st, will obey the disciplin ary rules of the program, will giverespect and obedien ce to American Scholar Group , Inc . asso ciates, and will keep communications open at all times.

6. We unde rstand and agree that the program participan t will no t take any non -prescribed drug s, drink alcoho lic beverage s, possessfalse identification, drive any motorized vehicle, or participate in any highly dangerous sport such as hang gliding, bungee jumping,etc. If the program participant violates any of the above guidelines, we understand that s/he may be immediately returned home atour family’s expense, and we accept full responsibility for any situation arising from his/her involvement the any of theseprohibited activities.

7. We understand that prolonged or inappropriate use of the internet, including e-mail or chat rooms, may result in a first warning andthen progressive discipline that will lead to program termination.

8. We agree that the program participant may not take any action that may change the nature of his/her life, i.e. getting married,changing religions, etc.

9. We understand and agree that the program participant will be subject to all of the laws of the host country. In the case of seriousinfraction of the rules and requirements governing the conduct of the program participant, or in the case of extreme homesickness,or poor adjustment to the host family or school, the participant may be returned home immediately at the discretion of AmericanScholar Group, Inc. and at the expense of our family.

10. We understand that the program participant may not drive any motorized vehicle that requires an operator’s license, nor be apassenger in a private plane. A student is permitted to register for school-sponsored driver education classes. If a license isobtained through this program, the license must be immediately given to an American Scholar Group, Inc. administrator. It will bereturned to the student on the day of departure for home.

11. We understand that as natural parents we are responsible for providing funds for the necessary day to day expenses for our son/daughter. The suggested amount is approximately $400.00 per month.

12. We agree that the program participants are allowed to go home during the program but usually only under emergency conditions andonly with prior approval from the American Scholar Group, Inc. main office. Visits from the natural parents and friends during theprogram are generally discouraged but can be arranged through the American Scholar Group, Inc. main office. Independent travelis not permitted at any time during the program, unless approved by the American Scholar Group, Inc. main office.

13. We agree that the program participant is to return home within 5 days after the last day of school.14. We agree to pay the early return of our son/daughter if it is deemed necessary for medical reasons after consultation among

ourselves, program personnel and designated medical authorities.15. We agree to pay for any medical and dental bills not covered by the accident and sickness insurance. We agree to pay for any

deductible amount due that the insurance policy might not cover.16. We agree that the program participant is to possess a return flight ticket from the Pittsburgh, Pennsylvania USA, airport to the

participant’s home country. This return ticket is to be carried to the United States by the participant and is to be kept in safekeepingby the participant until time for the participant to return home.

17. We agree to pay for any and all telephone calls made by the program participant including those calls made which might appear onthe host family’s telephone bill after the departure of the program participant.

18. We agree not to circumvent in any way the operating procedures of American Scholar Group, Inc. for the placement of students and understand that students who are originally placed by American Scholar Group, Inc. remain so unless released in writing by

American Scholar Group, Inc. 19. We give American Scholar Group, Inc. the right to use the participant’s name and photograph for reproduction in any medium for

the purposes of publication, advertising, trade, display or editorial use. 20. We agree to attend meetings that are scheduled to prepare us for the American Scholar Group, Inc. Study in America program experience.

____________________________________________________________________________ ______________________________________________________________________ Signature of Parent Date Signature of Student/Participant Date

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LIABILITY RELEASE

Student’s Name: __________________________________________________________________________________

We hereby release American Scholar Group, Inc. and all of its employees, field representatives and residential services administrators from all liability, damages or claims which I have incurred after the termination of the program.

We understand that the participant will be subject to the authorities and teachers of the school where s/he may be assigned and that s/he will have to follow all relevant rules related to his/her living environment. We also understand that American Scholar Group, Inc. reserves the right to terminate participation in the program of any participant whose conduct may be considered detrimental or incompatible with the interest and security of the program. If this decision is ever made, the participant and his/her parents or legal guardians will be formally warned and have no right to any refunds.

We accept the right of American Scholar Group, Inc. to directly or indirectly cancel, change or substitute in emergencies, or whenever normal circumstances change, those parts of the program whose alteration may be considered necessary. Should there be a geographic move of the student, the cost of transportation shall be mutually decided by American Scholar Group, Inc. and the international representative for the student’s home country.

We also grant American Scholar Group, Inc. the school where the participant may be assigned, and individuals or families with whom s/he may live, all necessary permissions to act as legal guardians and “in loco parentis” in any situation, especially in emergencies, whether medical or other, including the possibility of permission for surgical operations or any other treatment deemed necessary in a given set of circumstances.

We guarantee American Scholar Group, Inc. that, although we may maintain in the future a friendly relationship with the school, local coordinator, associates or family members with whom we may establish contact through American Scholar Group, Inc. or its employees, we will not make use of this knowledge to send in the future, directly or indirectly, our child, other students, relatives or friends directly to said school, local coordinators, associates or family members, unless it is through American Scholar Group, Inc.

The participant agrees to accept and uphold the standards of conduct set by American Scholar Group, Inc. the school where s/he may be assigned, and whatever residential environment to which s/he is assigned, for the duration of the program. S/he agrees to maintain friendly and respectful relations with his/her teachers and classmates and, especially, with all American Scholar Group, Inc. associates and family members with whom s/he may be living, to accept the rules of conduct imposed within the living environment, to participate in residential community or family life as much as possible, to try his/her best to adjust to the normal living systems in those environments, and to treat all fellow students and residential peers with respect.

SIGNATURE OF PARENT__________________________________________ DATE______________________

SIGNATURE OF STUDENT_________________________________________ DATE______________________

TRAVEL AUTHORIZATION

We, as Parents of the Undersigned Student, do hereby authorize American Scholar Group, Inc. Administrators at the Student’s school placement, and any family to whose home the Student may be assigned, the right as agents of the Undersigned Parents to make travel determinations for the student for the duration of the student’s participation in the Study in America Program.

It is understood that this Authorization is given in advance only when the Student is traveling and supervised by an American Scholar Group, Inc. Representative, School Administration Representative, Host Parent, or with tours sponsored by American Scholar Group, Inc. We understand that the Student may not travel unsupervised.

SIGNATURE OF PARENT__________________________________________ DATE______________________

SIGNATURE OF STUDENT_________________________________________ DATE______________________

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School Request Information Form

Below, you will find information on our program with choices the student or his/her parents can make in order to help in the school placement process. Please place a check next to the areas of interest on the form. There is also an opportunity to list three school choices for the student.

Please indicate your preferences below. Before your child’s placement is confirmed, we will contact your home country representative with program cost details, at which time you will have the option of accepting or rejecting the suggested placement.

Please note: Some American private or public high schools may also charge additional fees for ESL, books, uniforms, sports activities, etc. Again, these costs vary. In addition, please remember that typical U.S. ESL programs are not designed to assist foreign students toward the goal of speaking fluent American English. U.S. ESL programs are primarily designed to allow non-English-speaking individuals the opportunity to participate in classes without having to become fluent in English. If you desire intensive tutoring in speaking fluent American English, those services are available through the American Scholar Group, Inc. program.

Consider my child for: (you may check as many as you wish)

_____ Catholic High School _____ Christian High School _____ Non-Sectarian High School

_____ No religious affiliation _____ Intensive English tutoring _____ ESL

_____ Sports (list specific ones): _____________________________________________________________

_____ Advanced Placement classes (be specific): ________________________________________________

_____ Art classes _____ Music/Band classes _____ Drama classes

IF YOU HAVE ALREADY CONFIRMED A SPECIFIC SCHOOL OR SCHOOLS WITH YOUR HOME

COUNTRY REPRESENTATIVE, PLEASE LIST YOUR TOP THREE FAVORITE CHOICES, WITH YOUR

FAVORITE SCHOOL LISTED FIRST.

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

________________________________________ ________________________________________ Parent Signature Student’s Name (print clearly)

Page 3 of 3

Health Questionnaire

Physician’s Name _____________________________________________________

Student’s Name:_______________________________________________________Address:_____________________________________________________________ City:________________________________________________________________ Country:_____________________________________________________________ Telephone:___________________________________________________________

MEDICAL HISTORY – Have you had?

No Yes Measles No Yes Mumps No Yes Chickenpox No Yes Epilepsy No Yes Rubella

No Yes Sexually Transmitted Diseases No Yes Strokes No Yes Tuberculosis No Yes Malaria No Yes Broken Bones

No Yes Have you ever been hospitalized, had surgery, or been under extended medical care? If yes, for what reason?

SYSTEMIC REVIEW – Do you have the following?

Respiratory: No Yes Spitting Up Blood No Yes Chronic or Frequent Cough

Eyes-Ears-Nose-Throat: No Yes Eye disease or injury No Yes Do you wear glasses?No Yes Double vision No Yes Headaches No Yes Glaucoma No Yes Nosebleeds No Yes Ear disease

Skin: No Yes Skin disease, hives, eczema No Yes Jaundice No Yes Abnormal pigmentation

No Yes Have you been in good general health most of your life? If not, please explain.

ALLERGIES AND SENSITIVITIES – Is there a history of skin reaction or other reaction or sickness following injections or oral administration of:

No Yes Penicillin or other antibiotics No Yes Morphine, Codeine, Demerol, Oxycodone, other narcotics No Yes Aspirin, ibuprofen or other pain remedies No Yes Tetanus, antitoxin or other serums No Yes Any foods, such as egg, milk or chocolate

No Yes Novocain or other anesthetics No Yes Sulfa drugs No Yes Adhesive tape or latex (circle) No Yes Iodine or merthiolate No Yes Any other drug or medication

List: List:

No Yes Pets/Animals Please explain. No Yes Any other allergies? If yes, please list:

Have you ever received any medical attention or counseling for: No Yes Depression No Yes Eating Disorders (e.g., Anorexia or bulimia) If yes, please explain.

No Yes Concussion or Head Injuries No Yes Rheumatic Fever or Heart Disease No Yes DiabetesNo Yes CancerNo Yes SARS

Neck:No Yes StiffnessNo Yes Thyroid Trouble No Yes Enlarged Glands

No Yes Hearing Impaired No Yes Do you wear hearing aids?No Yes Dizziness No Yes Episodes of unconsciousness

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CLINICAL EVALUATION STUDENT’S NAME __________________________________ (to be filled out by family physician)

Normal Check each item Abnormal

Head, Face, Neck, Scalp Nose Sinuses Mouth and Throat Ears (int. & ext.) Ear drums (perforated) Eyes Ophthalmoscopic Pupils Ocular Motility Lungs and Chest Heart Vascular System Abdomen and Viscera

Normal Check each item Abnormal

Anus and Rectum Endocrine System G – U System Upper Extremities Lower Extremities Feet Spine, other Musculoskeletal Body Marks, Scars, Tattoos Skin, Lymphatics Neurologic Psychiatric Pelvis (female only) check how done vaginal

rectal

MEASUREMENTS AND OTHER FINDINGS

Height: _____________________ Weight: _______________________ Color Hair: _________________

Color Eyes: __________________ Build: slender _______ medium _______ heavy _______

BLOOD PRESSURE

Sitting: ______________________ Recumbent: ____________________ Standing: ___________________

PULSE (arm at heart level)

Sitting: ______________________ After Exercise: __________________ 2 Minutes After: _____________

Recumbent: __________________ After Standing 3 Minutes: ____________________________

LABORATORY FINDINGS

Urinalysis (A. Specific Gravity): Albumin _________________________ Sugar _________________________

Serology (Specify Test): _______________________________________ Blood Type & RH Factor: _________

Tuberculosis (Clearance must be within 6 months) BCG (TB Vaccine) Date: ___________________________

Skin Test: Date: _________________________ Positive or Negative: ______________________________

Chest X-Ray: Date: _________________________ Positive or Negative: ______________________________ (NB: if positive, chest x-ray information mandatory)

Type or Print Name of Physician: ______________________________________________________________________________

Address: __________________________________________________________________________________________________

Signature of Physician: ________________________________________________ Date of Exam: _________________________

We certify that the information supplied is true and complete to the best of our knowledge. We authorize any of the doctors, hospitals, or clinics mentioned above to furnish a complete transcript of medical records for purposes of processing this application.

Signature of Student: __________________________________________________ Date: ________________________________

Signature of Parent: ___________________________________________________ Date: ________________________________

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STUDENT’S NAME _________________________________ IMMUNIZATION RECORD

IMMUNIZATIONS REQUIRED FOR SCHOOL ADMITTANCE

Pupils enrolled in Kindergarten through Grade 12 (in the United States) are required to have written proof on file at their public or nonpublic school that they have been immunized against DPT (diphtheria, pertussis, tetanus), poliomyelitis, MMR (measles, mumps and rubella), hepatitis-B, and varicella (chickenpox). Failure to complete these immunizations is cause for exclusion from school. Required immunizations may vary from state to state.

MINIMUM IMMUNIZATION REQUIREMENTS:

Five or more doses of DPT, DT (pediatric), TD (adult) vaccine or a combination thereof.

Three or more doses of trivalent oral polio vaccine (TOPV).

Two doses measles vaccine.

Two doses mumps vaccine.

Two doses rubella vaccine.

Three doses of hepatitis B vaccine.

Two doses of varicella vaccine.

If the final dose of any of the above vaccines occurs before the third birthday, a booster shot is required.

IMMUNIZATIONS

DPT/DT 1.__________ date (mm/dd/yyyy)

2.__________ date (mm/dd/yyyy)




Booster, if required6.__________ date (mm/dd/yyyy)

TOPV ____________ (date of disease)




Booster, if required 4.__________ date (mm/dd/yyyy)

Measles ____________ (date of disease)




Mumps ____________ (date of disease)




Rubella ____________ (date of disease)




Varicella (chickenpox)

____________ (date of disease)




Hepatitis B 1.__________ date (mm/dd/yyyy)



Signature of Physician: ___________________________________________________________ Date: _____________________

Any immunizations not available in your country are available here, but they are expensive and are not covered by insurance. The student must be prepared to pay for any immunizations they receive in the USA. Please make every effort to obtain all immunizations before your departure from your home country.

Tetanus Toxide Booster


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AUTHORIZATION TO TREAT A MINOR

I (We) the undersigned parents(s), or legal guardian of:

________________________________________________, a minor, do hereby authorize and consent to any x-ray examination, anesthetic, or medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act, or a dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. Further, we (parents/guardian) want to assure you that we will reimburse any expenditure not covered by any accident and sickness insurance policies in effect at the time of medical treatment.

List any restrictions:

Allergies to Drugs or Foods:

List medications taken regularly:

Special medications or pertinent information:

Birthdate:___________________________

Family physician: _____________________________________________ Phone: ____________________________

Address: ___________________________________ City: _____________________ Country: __________________

Parent/Guardian Signature(s): __________________________________________________ Date: ________________

Address: ___________________________________ City: _____________________ Country: __________________

Telephone where Parent/Guardian may be reached:

Business: ___________________________ Home: _____________________________

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ASG Student App_CHECKLISTSECTION I_STUDENT APPLICATION_Rev 110114SECTION II_EDUCATIONAL INFORMATIONSECTION III_INSERTS revised 10-2014SECTION IV_HEALTH QUESTIONNAIRE

cb_cl_0: Offcb_cl_1: Offcb_cl_2: Offcb_cl_4: Offcb_cl_5: Offcb_cl_6: Offcb_cl_7: Offcb_cl_8: Offcb_cl_9: Offcb_cl_10: Offcb_cl_11: Offcb_cl_12: Offcb_cl_13: Offcb_cl_14: Offcb_cl_15: Offcb_cl_16: Offcb_cl_17: Offcb_cl_18_2: OffText1: Text5: Text7: Check Box1: OffCheck Box2: OffText8: Text12: Text13: Text14: LW: OffSC: OffSNS: OffSP: OffHF: OffKC: OffSCS: OffUH: OffCM: OffJFK: OffGHS: OffJHS: OffSHS: OffText37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text45: Text46: Text47: Text48: Family Name: First Name: Middle Name: Complete Mailing Address: Telephone No: EMail: Fax No: Date of Birth Month: Day: Year: Passport Number if known: FATHERS NAME: Address 1: Address 2: Country: Date of Birth: Speaks English: Business phone: Employed by: Occupation: MOTHERS NAME: Address 1_2: Address 2_2: Country_2: Date of Birth_2: Speaks English_2: Business phone_2: Employed by_2: Occupation_2: In emergency contact Phone number: Name: Birthdate: Gender: Living at home: cb1: Offcb2: Offcb3: Offcb4: Offcb5: Offcb6: Offcb7: Offcb8: Offcb9: Offcb10: Offcb11: Offcb12: Offcb13: Offcb14: Offcb15: Offcb16: Offcb17: Offcb18: Offcb19: Offcb20: Offcb21: Offcb22: Offcb23: Offcb24: Offcb25: Offcb26: Offcb27: Offcb28: Offcb29: Offcb30: Offcb31: Offcb32: Offcb33: Offcb34: Offcb35: Offcb36: Offcb7__1: Offcb37: Offcb38: Offcb39: Offcb40: Offcb41: Offcb42: Offcb43: Offcb44: Offcb45: Offcb46: Offcb47: Offcb48: Offcb49: Offcb50: Offcb51: Offcb52: Offcb53: Offcb54: Offcb55: Offcb56: Offcb61: Offcb62: Offcb63: Offcb64: Offcb66: Offcb67: Offcb68: Offcb69: Offcb70: Offcb73: Offcb74: Offcb75: OffPlease list any other specific interests hobbies and activities and any awards or commendations 1: Please list any other specific interests hobbies and activities and any awards or commendations 2: Other: If yes what instrument: Do you participate in any competitive sports: How often do you attend church: Are you active in any church groups: List the chores for which you are responsible at home 1: List the chores for which you are responsible at home 2: List the chores for which you are responsible at home 3: animals1: animals2: If yes what medication: How many years have you studied English: reason5: reason6: reason7: reason8: reason9: reason10: reason11: reason12: reason13: reason14: cb57: Offcb58: Offcb60: OffText2: STUDENTS NAME: cb7_1: Offcb7_2: Offcb7_3: Offcb7_4: Offcb7_5: Offcb7_6: Offcb7_7: Offcb7_8: Offcb7_9: Offcb7_10: Offcb7_11: Offcb7_12: OffEVALUATOR’S NAME: STUDENTS NAME_2: Excellent: Emotional stability and maturity: Selfreliance and independence 1: Selfreliance and independence 2: Selfreliance and independence 3: Impression she will make in US: Very Good 1: Very Good 2: Very Good 3: Very Good 4: Very Good 5: Very Good 6: Good 1: Good 2: Good 3: Good 4: Good 5: Good 6: Fair 1: Fair 2: Fair 3: Fair 4: Fair 5: Fair 6: Poor 1: Poor 2: Poor 3: Poor 4: Poor 5: Poor 6: Inadequate 1: Inadequate 2: Inadequate 3: Inadequate 4: Inadequate 5: Inadequate 6: Text3: English Teachers Name: School: Address: Tel number: Date of Interview: Date of Evaluation: CITY: COUNTRY: DAY: MONTH: YEAR: STUDENT: Date_7: Date_8: Students Name_3: DATE: DATE_2: DATE_3: DATE_4: CB_15_0: OffCB_15_26: CB_15_27: 1_4: 2_4: 3: Students Name: Physicians Name: Students Name_2: Address_2: City: Country_3: Telephone: cb9_33: Offcb9_39: Offcb9_45: Offcb9_51: Offcb9_53: Offcb9_59: Offcb9_65: Offcb9_95: Offcb9_97: Offcb9_3: Offcb9_8: Offcb9_14: Offcb9_20: Offcb9_26: Offcb9_1: Offcb9_7: Offcb9_13: Offcb9_19: Offcb9_25: Offcb9_29: Offcb9_5: Offcb9_11: Offcb9_17: Offcb9_23: Offcb9_6: Offcb9_12: Offcb9_18: Offcb9_24: Offcb9_30: Offcb9_32: Offcb9_36: Offcb9_42: Offcb9_48: Offcb9_55: Offcb9_61: Offcb9_67: Offcb9_34: Offcb9_40: Offcb9_46: Offcb9_52: Offcb9_54: Offcb9_60: Offcb9_66: Offcb9_70: Offcb9_31: Offcb9_35: Offcb9_41: Offcb9_47: Offcb9_38: Offcb9_44: Offcb9_50: Offcb9_37: Offcb9_43: Offcb9_49: Offcb9_69: Offcb9_71: Offcb9_57: Offcb9_63: Offcb9_58: Offcb9_64: Offcb9_56: Offcb9_62: Offcb9_68: Offcb9_72: Offcb9_76: Offcb9_80: Offcb9_84: Offcb9_88: Offcb9_92: Offcb9_Text5: cb9_73: Offcb9_75: Offcb9_77: Offcb9_79: Offcb9_81: Offcb9_83: Offcb9_85: Offcb9_87: Offcb9_89: Offcb9_91: Offcb9_93: OffText4: cb9_74: Offcb9_78: Offcb9_82: Offcb9_86: Offcb9_90: Offcb9_94: OffText6: p9t7: cb9_96: Offcb9_98: Offp9t8: p9t10: STUDENTS NAME_3: Check Box1100: OffCheck Box11013: OffCheck Box11026: OffCheck Box11039: OffCheck Box11001: OffCheck Box11012: OffCheck Box11024: OffCheck Box11036: OffCheck Box110011: Offcb10_11: Offcb10_22: Offcb10_33: Offcb10_10: Offcb10_20: Offcb10_30: Offcb10_01: Offcb10_9__0: Offcb10_18: Offcb10_27: Offcb10_0cb10_1: Offcb10_cb10_8: Offcb10_16: Offcb10_24: Offcb10_cb10_cb10_0: Offcb10_7: Offcb10_14: Offcb10_21: Offcb10_cb10_0: Offcb10_cb10_6: Offcb10_cb10_12: Offcb10_cb10_18: Offcb10_cb10_cb10_cb10_0: Offcb10_5: Offcb10_10cb10_1: Offcb10_15: Offcb10_cb10_cb10_cb10_cb10_0: Offcb10_4: Offcb10_8: Offcb10_cb10_12__1: Offcb10_0__0: Offcb10_3: Offcb10_6: Offcb10_9: Offcb10_0: Offcb10_1_2: Offcb10_1_0: Offcb10_1_1: Offcb10_1_5: Offcb10_1_6: Off1cb10_1_1_1: Offcb10_1_1_0: Offcb10_1_1_cb10_1_1_0: Offcb10_1_1_cb10_1_1_02: Offcb10_1_1_3: Offcb10_1_1_4: OffHeight: Weight: Color Eyes: Color Hair: slender: medium: heavy: Sitting: Recumbent: Standing: Sitting_2: After Exercise: 2 Minutes After: Recumbent_2: After Standing 3 Minutes: A Specific Gravity Albumin: Sugar: Specify Test: Blood Type RH Factor: BCG TB Vaccine Date: Date: Positive or Negative: Date_2: Positive or Negative_2: Type or Print Name of Physician: Address_3: Date of Exam: Date_3: Date_4: STUDENTS NAME_4: DPTDT: date mmddyyyy: date mmddyyyy_2: date mmddyyyy_3: date mmddyyyy_4: date mmddyyyy_5: date mmddyyyy_6: TOPV: date of disease: date mmddyyyy_7: date mmddyyyy_8: date mmddyyyy_9: Measles: date of disease_2: date mmddyyyy_11: date mmddyyyy_12: date mmddyyyy_13: Mumps: date of disease_3: date mmddyyyy_14: date mmddyyyy_15: date mmddyyyy_16: Rubella: date of disease_4: date mmddyyyy_17: date mmddyyyy_18: date mmddyyyy_10: date mmddyyyy_19: Varicella: date of disease_5: date mmddyyyy_20: date mmddyyyy_21: date mmddyyyy_22: date mmddyyyy_23: date mmddyyyy_24: date mmddyyyy_25: Date_5: a minor do hereby authorize and consent to any xray: t_12_1: t_12_2: t_12_3: t_12_4: Text9: Family physician: Phone: Address_4: City_2: Country_4: Date_6: Address_5: City_3: Country_5: Business: Home:

Check List - American Scholar Group · Check List SECTION I STUDENT APPLICATION – To be completed...

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Transcript of Check List - American Scholar Group · Check List SECTION I STUDENT APPLICATION – To be completed...