Student Master - SOD

School of Deaf

Extra Enrollment Information

Po / SSD #1

Date Referred

Department

Dorm

Dormitory

Performance Ind

SS Card

Bus Driver Name

Date Applied

F/R M Code

F/R Application

F/R Date Approved

F/R Comments

Tracking Information

CO

Pn / SD

Vis Rec

Relserv

Imp'ment

Supervising Teacher

Homeroom Teacher

Close out by IEP Date

T Date

L Date

N Date

Type

Excep

Glasses

Vis Date

C Date

C/B Test

Coch Im

Ext

C/B Test Date

Partial

Social Form

Time

Place

Parent Interview

Vis Comments

Medical Information

Parent Insurance

Policy #

Medicaid #

Medical Papers

Perm Shots

Medication

Medication

Hepatitis B

Current DPT

Allergies

HIB/Influenza

Diphtheria Date

TB Comments

TB Date

Sickle Cell

Seizures/Convulsions

MMR Date

Polio Date Imm

Cause of Deafness

Comment Med

Close

Take Off C - Remove from campus.