IMMUNIZATION RECORD FOR ALL INTERNATIONAL STUDENTS

Student Name: ________________________________________________

Date of Birth: ____/____/____ US Age ONLY

Day Mo Yr

IMMUNIZATION RECORD: To Be Completed By Physician

Vaccine

Date each dose was given

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

Day/Mo/Yr

Polio (TOPV)

__________

___________

__________

_________

DTP and or TD

___________

__________

(Diphtheria, Tetanus __________

____________

___________

__________

or whooping cough)

Td/Tdap

__________

____________

___________

__________

HIB

__________

____________

___________

__________

MMR

__________

(Combined)

(Separate

__________

Measles (Dose 1)

Measles (dose 2)

Mumps (dose 1)

Mumps (dose 2)

__________

Rubella (dose 1)

Rubella (dose 2)

Hepatitis B

__________

___________

Varicella

__________

___________

Varicella Disease __________

PneumoConju

__________

I have reviewed the records available, and to the best of my knowledge, the above name child has been

adequately immunized for school attendance as documenter above.

Physician or Clinic Address

____________________________________________

Physician Signature

____________________________________

Date; _____________________________

____________________________________

PHYSICAL FORM FOR ALL PARTICIPATING INTERNATIONAL STUDENTS (3 PAGES)

HEALTH CERTIFICATE

Student Name: ___________________________________

Date of Birth: ____/____/____

CERTIFICATE OF DENTAL HEALTH: To be completed by Dentist for Academic Students

I have examined the teeth of this student and certify that they are in satisfactory condition.

Dentist Signature: _____________________________________

Date: _____________

Dentist Name Printed __________________________________ Phone (____)_____________

City Code

Dentist’s Address: ______________________________________________________________

CERTIFICATE OF GENERAL HEALTH- A physician’s signature is needed for all students

PHYSICANS, PLEASE NOTE: This student will participate in an exchange program that involves living

overseas with a host family or in a dormitory. Please provide detailed information on any condition that could:

1) Impact the home chosen for this student or his/her adjustment to another culture:

2) restrict participation in activities or 3) possibly require treatment overseas.

Please type or print legibly in BLACK INK and write in ENGLISH. Upon completion of this form,

return it to the student. Thank you for your assistance.

Students Address ____________________________________________________________________________

___________________________________________________________________________________________

City

State/Province

Zip/Postal Code

Country

Date of examination: ___________ Age: _________ Sex ___ M ___F Height ____________ Weight _________

Blood Pressure: Sys: ________ Dia: ________ Pulse Rate: _______ Regular? ___ Yes ___ No

Are reflexes normal? Pupil: ____ Yes ___ No Knee: ____ Yes ____ No Other: ______________________

Please mark Yes or No for each of the following to indicate if the student has ever received treatment,

attention or advice from a physician or other probationer for, or been told by any physician or probationer

that such person had:

Yes

Date

Yes

Date

Chicken Pox

___

________

Allergies

___

________

Measles

___

________

Asthma

___

________

Mumps

___

________

Appendicitis

___

________

Poliomyelitis

___

________

Cough (Persistent)

___

________

Pneumatic Fever ___

___

________

Diabetes Mellitus

___

________

Rubella

___

________

Enuresis

___

________

Malaria

___

________

Headache

___

________

Hepatitis

___

________

Hernia

___

________

Parasites

___

________

Seizure

___

________

Learning Disability ___

___

________

Blindness

___

________

Sleepwalking

___

________

Dyslexia/Word

___

________

Depression

___

________

Anorexia

___

________

Attention Deficit ___

___

________

Bulimia

___

________

If answered YES ta any of the above, please provide any current status: -_______________________________

____________________________________________________________________________________________

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CERTIFICATE OF GENERAL HEALTH: CONTINUED

2. Does this student have any allergies _____ Yes

_____ No If Yes, please describe,

______________________________________________________________________________________

3. Is the student currently using any prescription / or medication? ____ Yes ____ No

If yes, give details and list the specific drugs being used. _______________________

_____________________________________________________________________

Has the student experienced disease, impairment or abnormality of any of the following?

Yes

Date

Abdominal Organs

_____

__________

Genitourinary System

_____

__________

Bone, Joints

_____

__________

Heart or Blood Vessels

_____

__________

Lungs, Respiratory System

_____

__________

Brain, Nervous System

_____

__________

Skin (Acne etc)

_____

__________

Ears or Hearing

_____

__________

Tonsils, Nose or Throat

_____

__________

Eyes or Vision

_____

__________

Varicose Veins

_____

__________

Additional Comments: ___________________________________________________________

_____________________________________________________________________________

Verification: I have completed/reviewed the above information, and it is accurate and complete.

_________________________________________

________________________________

Parent’s Signature

Date

_________________________________________

________________________________

Physician Signature

Date

HEALTH CLEARANCE- To be completed by Physician (Physician cannot be a family member)

PLEASE NOTE: In the event that the student’s medical information changes after the physician has completed this form,

VENTURE INTERNATIONAL ACADMEY/ VENTURE must be notified immediately.

Failure to notify VENTURE INTERNATIONAL ACADEMY/ VENTURE of the changes could result in dismissal

from the program or school.

Student Name ________________________________________________

Birth Date _______________________

Give your opinion of the general state of the student’s health.

______ Excellent

_____ Good

_____ Fair

_____ Poor

If this student’s health is fair or poor, please explain: __________________________________________________

___________________________________________________________________________________________

Have you noticed any abnormalities with the student’s blood pressure, pulse, or respiration or weight (gain/loss)?

_____ Yes

_____ No

If yes, please explain _______________________________________

_________________________________________________________________________________________

Are there any restrictions on the student’s participation in physical education and/or sports activities?

_____ Yes

_____ No

If yes, please explain _______________________________________

_________________________________________________________________________________________

Are you aware of any medication that the student is currently taking?

_____ Yes

_____ No

If yes, please list the medication, reason for the use and dosage

____________________________________________

PAGE 2

HEALTH CLEARANCE CONTINUED:

Student Name _____________________________________

Date of Birth ________________________

To your knowledge, is there a history of,or present evidience of, a nervous, emotional or eating disorder?

Please note that studying abroad involves significant adjustment to a foreign person, host family, school and community,

which often causes emotional stress. If the candidate is currently experiencing emotional, physical or personal issues,

these stresses can be aggravated by the adjustment demands of the program,.

_____ Yes

_____ No

If yes, please explain _______________________________

_________________________________________________________________________________________

In your professional opinion, do you give medical clearance for this student to participate in a study abroad program?

_____ Yes

_____ With reservation _____ No Comments _________________________

Any additional comments on students health: ____________________________________________________

_________________________________________________________________________________________

ONLY IF the student wears glasses or contact lenses, please complete the following ophthalmic information:

Sphere

Cylinder

Axis

Prism

Base

(OD) Ocular Dexter

________________________________________________________________

(OS) Ocular Sinister

________________________________________________________________

Add: ________________

Base Curve: ______________________________

Other: ___________________________________________________________________________________

I, the undersigned physician, have given a thorough physical examination and reviewed the medical history

of the candidate and certify that all important medical information has been included and that the above

information is accurate.

______________________________________________

Address: ________________________

Physician Name (Please print)

________________________________

______________________________________________

Date: ___________________________

Physician’s Signature

PAGE 3

ENGLISH TEACHERS EVALUATION

VENTURE INTERNATIONAL ACADEMY

FOREIGN LANGUAGE RECOMMENDATION: This form is for your ENGLISH teacher ONLY. Only to be completed for

the student whose name appears on this form. Please return these pages to the student in a sealed envelope to be

enclosed in the full application. Please provide a through and honest assessment of the student’s language capabilities

and place an official school stamp on the final page.

Student Name: _________________________________________________________________

Which language(s) has the student studied? __________________________________________________

How long have you been this student’s teacher? ________________ Year(s) _______________ Month(s)

Regardless of the student’s English proficiency, there will be periods of difficulty and frustration a s the student

begins to speak the foreign language on a daily basis. Please keep in mind as you evaluate this student’s foreign

language ability. Your evaluation will be used to help determine the student’s eligibility for the academic year program.

Reading Comprehension: Give a newspaper or magazine article of at least five (5) paragraphs, the student is able to:

_____ Excellent

Understand and explain its meaning clearly and completely (9 out of 10 words)

_____ Good

Understands most of its meaning

( 7-8 out of 10 words)

_____ Fair

Understand the basic vocabulary and idea of the article

(5-6 out of 10 words)

_____ Poor

understood very little of the article’s meaning

(1-4 out of 10 words)

Writing: When asked to write a short essay stating an opinion about his or her school, town, the student is able to:

_____ Excellent

Writes with near fluency using sentences, abstract terms, and strong vocabulary,

Uses the grammar of the language rather than composing the grammar of English into the foreign language.

_____ Good

Writes lengthy and sensible sentences and uses good vocabulary, Uses extremely

irregular grammar however meaning of composition is clear.

_____ Fair

Writes only simple sentences and uses basic vocabulary. Uses extremely irregular grammar,

meaning can be understood with effort.

_____ Poor

Writes incomplete, short or basic sentences using very limited vocabulary.

At times it is difficult to understand what the student means.

Additional Comments: ______________________________________________

______________________________________________

PAGE 1

ENGLISH TEACHER EVALUATION CONTINUED

Speaking and Understanding Conversation: After engaging the student for 15 minutes of active ENGLISH

language conversations using both abstract terms and kinematics phrases, rate the student’s ability to speak

and understand the ENGLISH LANGUAGE.

_____

Fluent

Student is able to understand and converse using sophisticated vocabulary and correct

sentence structure, The student does not have trouble with abstract subjects or most idioms.

_____

Nearly

Uses with sentences structures, The student can understand and respond to difficult

Fluent

questions. English language knowledge includes abstract terms. Student will have no

problems with communicating.

_____

Excellent English language responses although not perfect, come naturally. Has a very good

vocabulary and understands almost everything. Can respond intelligently when

speaking the language.

_____

Very

Student understand most conversation. Speaking ability is good and will get better with

Good

practice. Student can go beyond basic responses, The student knows a large vocabulary

however is clearly thinking in there language then translating to English.

_____

Good

Student understands the basic English language. Vocabulary includes most common

terms. The student becomes a little confused when the conversation involves abstract

terms, Student makes mistakes, however is understandable with the ability to carry on

basic conversation.

_____

Fair

Student can understand much more than she/he can communicate. Student can respond

with understandable sentences even though grammar is structure are not perfect. The

student needs more practice but should improve quickly in the host family and school.

_____

Satis-

Student understands the basic English language sentences and is able to respond, if only

factory in words or phrases. Grammar and sentence construction is poor, but understandable.

(A few weeks of foreign language immersion will improve his/her ability greatly).

_____

Novice Student understands words and phrases but not complete sentences. Speaking ability is

also limited to a few works or phrases. Student will have a hard time at the beginning, but

has the ability to succeed if willing to work hard.

_____

Poor

Student understands a few words but has little or no ability to communicate beyond a few

words. Student may even refuse to use foreign language.

_____

Unsat-

Student is unable to understand conversation and knows very little foreign language.

isfactory

Please comment on the student’s motivation and student habits.

_________________________________________________________________________________________________

Print Full Name _____________________________________________ Title ________________________________

Signature _________________________________________________ Date ________________________________

Please attach any certificates or test results obtained from English language competency test(s).

PAGE 2