Columbia Adventist Academy

Southern Union Conference

School Entry Medical Examination

Physician should complete this form on children initially entering Southern Union Schools.

Child's Name Date of Birth
Parent's/Guardian's Name Telephone Number
Address

I have examined the above named child and obtained a medical history.  The following medical findings were noted:

Hearing
Visual
Other

There were no apparent medical findings which restrict participation in routine school activities.

The following is a list of medical finds, activities that should be restricted, and length of restriction:

Medical Findings

Restricted Activities

Restriction End Date

 
Physician's Signature Date
Address
Office Phone No.

Form #110691 Supplement


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