2017-2018 HIGH SCHOOL REGISTRATION CHECKLIST

This checklist should be used to help you ensure all required registration documents are provided to

register your child with MOT Charter School.

Please note: If we do not receive all required documents within 30 days of the registration packet

mailing date, your student will be withdrawn and their seat will be offered to the next applicant on the

waiting list. You may return the completed forms by one of the following ways:

Email: hsfrontoffice@motcharter.com

Mail or Hand Deliver to:

MOT Charter School, 1275 Cedar Lane Road, Middletown, DE 19709

Fax: 302-696-2001

_______ Copy of the most recent physical examination (from your child’s physician)

In order to start school, the State of Delaware requires all new students to have a

physical examination that is no more than one year old as of August 28, 2017. You

should provide the most recent copy available now, then update the physical information

if you child is scheduled for an annual exam between now and August 28, 2017.

_______ Immunization record (from your child’s physician)

You should provide the most recent copy available now, then update the information if

you child is scheduled for an annual exam between now and August 28, 2017.

_______ Transportation Information Form (attached)

_______ Emergency Data and Health Information (attached)

_______ School Alerts (attached)

_______ Delaware Department of Education - Agricultural Work Survey (attached)

_______ Delaware Department of Education - Home Language Questionnaire (attached)

_______ Request for Student Records (if applicable)

_______ Most recent report card and/or standardized test results (if applicable)

2017-2018 EMERGENCY DATA AND HEALTH INFORMATION

STUDENT INFORMATION

Last Name:_______________________ First Name:__________________ M.I. ______Date of Birth: _______________

Student’s Home Address: ______________________________City __________________State _______ZIP__________

Development____________________________________ Home Telephone: ___________________________________

PRIMARY CONTACT

Last Name:____________________ First Name:________________ M.I. ____ Relationship to Student: ______________

Address: __________________________________________City:__________________ State: ______ ZIP___________

Development______________________ Telephone: ______________________ Cell Phone: _______________________

Place of Employment: ___________________________________Business Telephone: _________________Ext._______

Email: ____________________________________________________________________________________________

Is the Primary Contact a custodial parent or guardian? YES________ NO_________

SECONDARY CONTACT

Last Name:____________________ First Name:________________ M.I. ____ Relationship to Student: ______________

Address: __________________________________________City:__________________ State: ______ ZIP___________

Development______________________ Telephone: ______________________ Cell Phone: _______________________

Place of Employment: ___________________________________Business Telephone: _________________Ext._______

Email: ____________________________________________________________________________________________

Is the Secondary Contact a custodial parent or guardian? YES________ NO_________

IF THE PRIMARY AND SECONDARY CONTACTS CANNOT BE REACHED, PLEASE CALL:

Primary Emergency Contact

Last Name:____________________ First Name:________________ M.I. ____ Relationship to Student: ______________

Address: __________________________________________City:__________________ State: ______ ZIP___________

Home Telephone:__________________ Work Telephone: __________________ Cell Phone: _____________________

Secondary Emergency Contact

Last Name:____________________ First Name:________________ M.I. ____ Relationship to Student: ______________

Address: __________________________________________City:__________________ State: ______ ZIP___________

Home Telephone:__________________ Work Telephone: __________________ Cell Phone: _____________________ (Continued on the reverse side)

IN ADDITION TO THE PRIMARY AND SECONDARY CONTACTS, THE FOLLOWING PEOPLE MAY

PICK UP MY CHILD FROM SCHOOL:

Last Name:________________________ First Name:___________________ Relationship to Student: _______________

Home Telephone:___________________ Work Telephone: _________________ Cell Phone: _____________________

Last Name:________________________ First Name:___________________ Relationship to Student: _______________

Home Telephone:___________________ Work Telephone: _________________ Cell Phone: _____________________

MEDICAL INFORMATION

Physician’s Name: _____________________________________________ Telephone: ___________________________

Dentist’s Name: _______________________________________________ Telephone: ___________________________

Indicate any serious medical issues:

__________________________________________________________________________________________________

Indicate any medications your child regularly takes:

__________________________________________________________________________________________________

Indicate any allergies the child has and specify if an allergy is life-threatening (must provide a physician’s allergy

action plan):

__________________________________________________________________________________________________

Medical Insurance Provider: _________________________________________________________________________

__________________________________________________________________________________________________

Certificate Number Group Number Type

In the event of an illness or emergency, parents are expected to pick up their child within an hour of notification from school.

Emergency contacts should be within one hour driving distance from the school.

MOT Charter School will follow the procedures below when caring for a child who becomes sick or injured at school:

1. The school nurse will call the home.

2. If there is no answer at home, the school nurse will call the place of employment of the primary and/or secondary contacts.

3. If there is no answer at home or at the place of employment, the school nurse will call the primary and/or secondary emergency

contacts and the family physician.

4. If none of the above answer, the school nurse will call an ambulance, if necessary, to transport the child to a local medical facility.

5. Based upon the judgment of the attending physician, the child may be admitted to a local medical facility.

6. The school will continue to call parent/guardians, emergency contacts, and physician until someone is reached.

If I cannot be reached and the school authorities have followed the procedures described, I agree to assume all expenses for moving

and medically treating this student. I also hereby consent to any treatment, surgery, diagnostic procedures or the administration of

anesthesia which may be carried out based on the medical judgment of the attending physician. I will promptly notify the school if

any of the above information changes.

Parent/Guardian Signature _____________________________________________Date ________________________

Parent/Guardian Signature _____________________________________________Date ________________________

All custodial parents/guardians must sign this Emergency Data and Health Form.

2017-2018 HIGH SCHOOL TRANSPORTATION INFORMATION 

Last Name: _________________________________ First Name: ___________________ Grade:______

Morning Transportation TO School Service Requested

Afternoon Transportation FROM School Service Requested

Street Address: _____________________________ Street Address: _____________________________

City: ___________________________ City: ___________________________

Transportation Service Requested

Please select one for morning and afternoon, or if transportation needs are the same to and from school, check here

Walker: will walk to school Walker: will walk to school

Car Rider: will be dropped off at school between 7:15 am and 7:25 am and picked up after school at 2:30 pm or following an afterschool activity

Car Rider: will be dropped off at school between 7:15 am and 7:25 am and picked up after school at 2:30 pm or following an afterschool activity

Bus Rider: will need bus transportation to and from school

Bus Rider: will need bus transportation to and from school

NOTE: Students who live outside of the Appoquinimink School District will be picked up and dropped off at a designated hub stop. Please select the hub stop that you would prefer from the list below:

______ Rte 4 & 72-Pencader Plaza-Newark ______ Rte 40 & 72-Fox Run Shopping Plaza ______ Rte 896–People’s Plaza ______ Rte 13–New Castle Farmer’s Market (KFC) ______ Rte 13/Rte 40 split–Walmart ______ Rte 40-Bear Library ______ Rte 71-Red Lion United Methodist Church

______ Rte 13-Park & Ride- North St. Georges

______ Rte 13–Acme Markets Plaza, Smyrna

NOTE: Students who live outside of the Appoquinimink School District will be picked up and dropped off at a designated hub stop. Please select the hub stop that you would prefer from the list below:

______ Rte 4 & 72-Pencader Plaza-Newark ______ Rte 40 & 72-Fox Run Shopping Plaza ______ Rte 896–People’s Plaza ______ Rte 13–New Castle Farmer’s Market (KFC) ______ Rte 13/Rte 40 split–Walmart ______ Rte 40-Bear Library ______ Rte 71-Red Lion United Methodist Church

______ Rte 13-Park & Ride- North St. Georges

______ Rte 13–Acme Markets Plaza, Smyrna

Student Name:_________________________

2017-2018 SCHOOL ALERTS

MOT Charter School utilizes a telephone broadcast system to notify MOT Charter families of unplanned events

and emergencies, such as early dismissals, school cancellations, and school delays. We also use this service

from time-to-time to communicate general announcements or reminders. When utilized, the service will, within

minutes, deliver a recorded message from the school to all telephone numbers in our selected contact lists.

Please initial below your consent to receive automated telephone calls from MOT Charter School:

______ Non School Hours Emergency (Call Student home telephone, Call both Parent/Guardian Cell Phones

and Text to both Parent/Guardian Cell Phones)

______ School Hours Emergency (Call Student home telephone, Call both Parent/Guardian Cell and Work

Phones, Call to Emergency Contact(s) Home, Cell and Work Phones and Text to both Parent/Guardian Cell

Phones)

______ Transportation (Call Student home telephone, Call both Parent/Guardian Cell Phones and Text to both

Parent/Guardian Cell Phones)

______ General (Call Student home telephone, Call both Parent/Guardian Cell Phones and Text to both

Parent/Guardian Cell Phones)

The home telephone number of the student will be used every time we send a message through

SchoolMessenger, regardless of the urgency of the message.

In the space below you may provide an additional telephone number if you wish us to include it in the school

alert system for emergency messages in addition to the Primary and Secondary contacts listed on the students’

Emergency Data form.

Name:___________________________________ Relationship to Student: ________________________

Telephone Number: ____________________________________________________________________

Electronic Messages from School

When communicating to families through email, we will use the home email addresses of the Primary and

Secondary contacts listed on the students’ Emergency Data form. If there is another email address you would

like us to use for school announcements, newsletters and other school wide electronic communications, please

provide that information below:

Name:___________________________________ Relationship to Student: ________________________

Email Address: ________________________________________________________________________

PTO Announcements

The MOT Charter School PTO plays an important role in our school community, including hosting many family

events and celebrations. Please indicate below if you do not want your contact information shared with the PTO.

____ Please do not share my contact information with the MOT Charter School PTO.

2017-2018 REQUEST FOR TRANSFER OF HIGH SCHOOL

RECORDS

Student Information

Last Name:____________________________ First Name: __________________ Middle:____

Date of Birth:________________________________ Entering Grade Level: ______________

Previous School Information

School Name: ____________________________________ Telephone: ___________________

City:_________________________ State: ____ ZIP: ________ Fax Number: _______________

Last Grade Level Completed____________

The above-named student has registered to attend MOT Charter School beginning in the 2017-2018

school year. Please forward all pertinent scholastic, disciplinary, health, and psychological information

(including any transcripts of grades, attendance records, immunization records, test scores, vision and

hearing results, any emergency health care plans, Individual Education Plans, psychological testing

results, 504 plans).

Please send the records to:

MOT Charter High School

1275 Cedar Lane Road

Middletown, DE 19709

ATTN: Front Office

hsfrontoffice@motcharter.com

**********************************************************************************

With my signature below, I give my permission to the above-named school to release and transfer the

requested records to MOT Charter School.

___________________________________________

Parent/Guardian Name (Please Print)

___________________________________________ Date______________________

Parent/Guardian Signature

THE DELAWARE DEPARTMENT OF EDUCATION IS AN EQUAL OPPORTUNITY EMPLOYER. IT DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX,

SEXUAL ORIENTATION, GENDER IDENTITY, MARITAL STATUS, DISABILITY, AGE, GENETIC INFORMATION, OR VETERAN’S STATUS IN EMPLOYMENT, OR ITS PROGRAMS AND ACTIVITIES.

DEPARTMENT OF EDUCATION Townsend Building

401 Federal Street Suite 2 Dover, Delaware 19901-3639

DOE WEBSITE: http://www.doe.k12.de.us

Steven H. Godowsky Secretary of Education Voice: (302) 735-4000

FAX: (302) 739-4654

Delaware Department of Education Home Language Survey

Date:_________________ School:________________________ Delaware Department of Education requires schools to determine the language(s) spoken at home by each student. This information is essential in order for schools to provide meaningful instruction for all students. Please complete the portion below and return this survey to your child's school. 1) Parent’s information: (Section 1 is for the parent/guardian’s preferred language. The student information is in

Section 2.) a) In what language would you like to receive written information from the school? _________________ b) In what language would you prefer to communicate orally with school staff? _____________________

2) Student's Information: Last/ First/ Middle Name_________________________________ Grade _______________Age_______

A. 1. Which language(s) does your child currently . . .

a. understand?_________________ b. speak?______________ 2. Which language does your child most often use…

(1) at home with parents?___________________ (2) at home with siblings?___________________ (3) at home with extended family members? ________________ (4) Outside of school (with friends, for recreational activities)?_______________

ii) Which language does your child most often hear ... (1) at home with parents?____________________ (2) at home with siblings?_____________________ (3) at home with extended family members? ______________________ (4) Outside of school (with friends, for recreational activities)?______________________

B. 1. Which language did your child speak when he/she first began to speak?___________________ 2. What other languages does your child regularly use/hear? _____________________

3. Does your child read/write in English? Yes No 4. Does your child read/write in a language other than or in addition to English? Yes No

3) Additional services may be provided to your child based on the date of his/ her arrival and enrollment in US

schools. 1. Your child was born in what country? _____________________ 2. If your child was born in another country, has she/he ever attended a school in the United States? Yes No 3. If yes, what was the date that your child enrolled in a U.S. school? __/__/____

Parent/Legal Guardian Signature____________________________ Date ______________________ DISTRICTS: a COPY of this form must be included in the district/charter registration packet and distributed to all students. The completed form must be retained in the student's file to document compliance with the Title Ill federal program requirements. If another language is indicated on the form, a COPY of the completed form should be routed to the LEA English as Second Language Department.

DELAWARE DEPARTMENT OF EDUCATION MIGRANT EDUCATION PROGRAM Agricultural Work Survey

Dear Parent/ Guardian,

In order to better serve your child, ______________________, the __________________ ______ District/Charter School is

helping the State of Delaware identify students who may qualify to receive additional education and support services.

The information provided below will be kept confidential. Please answer the following questions and return this form to

your child’s school.

1. In the past 3 years, has your family changed from: a) one school district to another; b) one state to another state;

c) another country to the U.S.?

YES NO

If “NO,” then you do not need to complete the remainder of this survey. If “YES,” please continue.

2. Was the reason for this change to look for or to accept a job in an agricultural or fishing activity such as those listed

below? Answer this question even if you have a different type of job now.

YES NO

If “YES,” please circle all that apply if you or your husband/wife, or someone in your household has worked with, on, or in a:

Farm Chicken processing plant Dried or dehydrated fruits/spices Plant nursery/greenhouse

Dairy Processing meat/fish Sod farms Tree growing or harvesting

Ranch Cranberry bogs Meat or food packing plant Food processing

Cannery Fresh/frozen juices Mushrooms Pet food processing

Chicken house Fishery Planting, picking, or packing fruits, vegetables, seeds, or nuts

Cleaning, weeding or preparing land for planting

Please add any other agricultural or fishing work/activity that you or your husband/wife or someone in your household has performed:

___________________________________ _______

Please list all children ages 3-21 years old in the home, including those not enrolled in school:

First / Last name Date of Birth Age Grade School

Parent/Guardian: ____ _____ Date:

Address: _______________ Apt. No. _________ City: Zip:

Phone: _____________________ Best time to be reached ____________ AM / PM Alternate or cell phone number: _______ _ _____

June 2014

DISTRICTS: a COPY of this form must be retained in the student’s file to document compliance with the Title I, Part C federal program requirements. The ORIGINAL document must be submitted to the Delaware Department of Education Migrant Education Program Office via State mail to Code D370B or by U.S. Postal Service to 401 Federal Street, Suite 2, Dover, DE 19901.

(Insert District / Charter School Name)

MOT Charter School

School Calendar

2017-2018

Wednesday August 23 Practice Bus Run for New Kindergarten Students

Monday August 28 First Student Day, Grades K-9

Tuesday August 29 First Student Day, Grades 10, 11 & 12

Monday August 28 Kindergarten Boo-Hoo/Yahoo Breakfast

Monday September 4 Labor Day -- School Closed

Thursday September 7 Picture Day

Friday October 6 Half Day for Students/Half Day Professional Development

Monday October 9 Columbus Day -- School Closed

Thursday October 19 Picture Retakes

Friday November 10 Veterans Day -- School Closed

Monday November 20 Half Day for Students/Half Day Parent Teacher Conference

Tuesday November 21 Parent-Teacher Conferences - No Classes for Students

Wednesday - Friday November 22 - 24 Thanksgiving Holiday -- School Closed

Monday Dec. 25 – Jan. 1 Winter Break -- School Closed

Tuesday January 2 Professional Day – No Classes for Students

Monday January 15 Martin Luther King, Jr. Day -- School Closed

Friday February 16 Professional Day – No Classes for Students**

Monday February 19 Presidents' Day -- School Closed

Friday March 9 Professional Day – No Classes for Students**

Friday March 30 Good Friday – School Closed

Monday - Friday April 2-6 Spring Break -- School Closed

Monday May 28 Memorial Day -- School Closed

Friday June 8 Last day for students ½ day

Monday - Friday June 11-15 Weather Contingency Days

**Professional Development days on February 16th and March 9th are designated as potential make-up days

in the event that we have cancellations due to weather or other emergencies. More than two cancellations

will require additional make-up days after June 8th.

Cover November 2016

DELAWARE STUDENT HEALTH FORM – ADOLESCENT

Grades 7-12

To be completed by licensed healthcare provider:

Physician (MD or DO), Clinical Nurse Specialist (APN), Advanced Practice Nurse (APN), or Physician’s Assistant (PA)

To Parent or Guardian:

In order to provide the best educational experience, school personnel must understand your child’s health needs.

This form requests information from you (Part I) and your health care provider (Parts I, II and III). All students in

Delaware public schools must provide documentation of current immunizations. Beginning in August 2016, students

entering Grade 9 must have had an adolescent booster dose of Tdap and one dose of meningococcal vaccine.

Additionally, a current (within 2 years) health examination is required upon school entry and prior to Grade 9.

Talk with your health care provider about important issues1 regarding your child, such as:

Physical Growth and Development (physical and oral health; body image; healthy eating; physical

activity)

Social and Academic Competence (connectedness with family, peers, school, and community;

interpersonal relationships; school performance)

Emotional Well-Being (coping; mood regulation and mental health; self-esteem; sexuality)

Risk Reduction & Safety (tobacco; alcohol or other drugs; pregnancy; STIs; infection; disaster planning)

Violence & Injury Prevention (safety belt and helmet use; substance abuse and riding in a vehicle; abuse

protection; guns; interpersonal violence [fights/dating violence]; bullying)

Immunizations

Immunizations Required for Newly Enrolled Students at Delaware Schools

GRADES 7-12:

DTaP/DTP, Td/Tdap: Completion of the primary series plus an adolescent booster dose of Tdap administered

at age 11-12 or prior to entry into Grade 9.

Polio: 3 or more doses. If the 3rd dose was prior to the 4th birthday, a 4th dose is required.

MMR2: 2 doses. The 1st dose should be given on or after the 1st birthday. The 2nd dose should be given after

the 4th birthday.

Hep B2: 3 doses. For children 11 to 15 years old, two doses of a vaccine approved by CDC may be used.

Varicella3: 2 doses. The 1st dose must be given on or after the 1st birthday.

Meningococcal: 1 dose is required for entry into Grade 9. A second dose is recommended by the Division of

Public Health for all adolescents.

Immunizations Strongly Recommended by the Delaware Division of Public Health

Influenza (seasonal) vaccine: each year for all children (6 months and up).

Human papillomavirus vaccine (HPV): all girls and boys (ages 11 or 12)

Pneumococcal vaccine (PCV13): children with specific risk factors

Pneumococcal vaccine (PPSV): certain high risk groups

Hepatitis A: unvaccinated children who are or will be at increased risk

1Clinicians refer to: Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, (3rd Ed.) AAP, 2008 2Disease histories for measles, rubella, mumps and Hepatitis B will not be accepted unless serologically confirmed. 3Varicella disease history must be verified by a health care provider to be exempted from vaccination. 4A new school enterer is a child entering a Delaware school district for the first time.

SAM

PLE

FORM

CHILD’S NAME

Page 1 November 2016

PART I – HEALTH HISTORY

To be completed by parent/guardian prior to exam

The healthcare provider should review and provide comments in the last column.

Name: Gender: DOB:

Date: Examiner:

PARENT HEALTHCARE PROVIDER COMMENT

Developmental delay (speech, ambulation, other)? Yes No

Serious injury or illness?

Medication?

Hospitalizations?

When? What for?

Surgery? (List all)

When? What for?

Ear/Hearing problems?

Heart problems/Shortness of breath? Yes No

Heart murmur/High blood pressure? Yes No

Dizziness or chest pain with exercise? Yes No

Allergies (food, insect, other)? Yes No

Family history of sudden death before age 50? Yes No

Child wakes during the night coughing? Yes No

Diagnosis of asthma? Yes No

Blood disorders (hemophilia, sickle cell, other) ? Yes No

Excessive weight gain or loss? Yes No

Diabetes? Yes No

Loss of function of one or paired organs (eye, ear,

kidney, testicle)?

Seizures? Yes No

Head injuries/Concussion/Passed out? Yes No

Muscle, Bone, or Joint problem/Injury/Scoliosis? Yes No

ADHD/ADD? Yes No

Behavior concerns? Yes No

Eye/Vision concerns?

Glasses Contacts

Other_______________________

Yes No

Dental concerns?

Braces Bridge Plate Other?

Date of exam ________________________

Yes No

Other diagnoses? Yes No

Does your child have health insurance? Yes No

Does your child have dental insurance Yes No

Information may be shared with appropriate personnel for health and educational purposes.

Parent/Guardian

Signature Date

SAM

PLE

FORM

CHILD’S NAME

Page 2 November 2016

PART II IMMUNIZATIONS

Entire section below to be completed by MD/DO/APN/NP/PA

Printed VAR form may be attached in lieu of completion.

Immunizations – Shaded Vaccines Required. Regulation is located at Title 14 Section 804: Immunizations

DTaP/ DT

/ /

DTaP/ DT

/ /

DTaP/ DT

/ /

DTaP/ DT

/ /

DTaP/ DT

/ /

OPV/ IPV

/ /

OPV/ IPV

/ /

OPV/ IPV

/ /

OPV/ IPV

/ /

OPV/ IPV

/ /

PCV7/ PCV13

/ /

PCV7/ PCV13

/ /

PCV7/ PCV13

/ /

PCV7/ PCV13

/ /

PCV7/ PCV13

/ /

Hib

/ /

Hib

/ /

Hib

/ /

Hib

/ /

MMR

/ /

MMR

/ /

HepB /HepB-2

/ /

HepB /HepB-2

/ /

HepB

/ /

VAR

/ /

VAR

/ /

RV-2/ RV-3

/ / RV-2/ RV-3

/ / RV-3

/ /

MCV4

/ /

MCV4

/ /

HPV

/ /

HPV

/ / HPV

/ /

Hep A

/ /

Hep A

/ / Td/Tdap

/ /

Td/ Tdap

/ /

Td

/ /

Influenza

/ /

Influenza

/ /

PPSV23

/ /

PPSV23

/ /

Other:

/ /

Other:

/ /

Other:

/ /

Other:

/ /

Other:

/ /

Child is fully immunized per DPH/CDC recommendations (refer to cover page) Yes No

PART III – SCREENING & TESTING

Entire section below to be completed by MD/DO/APN/NP/PA

Scr

een

Height: _______Weight: _______BMI: _______ BMI Percentile: _______BP: ________Pulse: ________Other: ________

(inches) (pounds)

Den

tal

Scr

een

Problem Identified: Referred for treatment

No Problem: Referred for prevention

No Referral: Already receiving dental care

Tu

ber

culo

sis

Scr

een

All new enterers must have TB test or TB Risk Assessment, which must be done within 12 months prior to school entry.

Risk Assessment: Date__________ Results: Test Required Test Not Required

Mantoux Skin Test: Date__________ Results:____________________MM

Other: (type)_______________ Date__________ Results:____________________MM

O

ther

S

cree

n

Hearing: Type:_______________ Date:_________ Results:________________ Referral: No Yes ______ Date

Vision: Type:_______________ Date:_________ Results:________________ Referral: No Yes ______ Date

Other: Type:_______________ Date:_________ Results:________________ Referral: No Yes _____ Date

SAM

PLE

FORM

CHILD’S NAME

Page 3 November 2016

PART IV – COMPREHENSIVE EXAM

Entire section below to be completed by MD/DO/APN/PA

PHYSICAL

EXAMINATION

Check ()

NORMAL ABNORMAL

HEALTHCARE PROVIDER COMMENT

General Appearance

Skin

Eyes

Ears

Nose/Throat

Mouth/Dental

Cardiovascular

Respiratory

Endocrine

Gastrointestinal

Genito-Urinary

Neurological

Musculoskeletal

Spinal examination

Nutritional status

Mental health status

FOR CHRONIC & LIFE THREATENING CONDITIONS:

Children with life-threatening conditions need an emergency care plan for school.

Please attach care plan, protocols, and/or emergency care plan.

Recommendations or Referrals:

DIAGNOSIS EMERGENCY PLAN

ATTACHED

CARE PLAN OR

PRESCRIPTION

PLAN ATTACHED

YES NO YES NO

Print Name: __________________________ Signature: ____________________________Date: ______

Physician (MD or DO) Clinical Nurse Specialist (APN) Advanced Practice Nurse (APN) Physician Assistant (PA)

Address: ____________________________________________________Phone: ______________________

SAM

PLE

FORM