PDF《The SMIC PRIVATE SCHOOL 上海市民办中芯学校》

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9 请确认学生是否接受过这些疾病的治疗 Please check if student has received medical treatment for any of the following conditions: Yes No Yes No Yes No ADHD 过动儿 Dizziness 晕眩 Tuberculosis 肺结核 Anemia 贫血 Frequent Colds 习惯性感冒 Vision Problems 眼疾 Asthma 气喘 Pneumonia 肺炎 Nephritis 肾炎 Adenoidectomy 肾上腺切除 Hearing Problems 听力障碍 High Blood Pressure 高血压 Cancer/Tumor 癌症 Heart Problems 心脏病 Dyslexia 诵读困难 Gastric Ulcer 胃溃疡 Epilepsy 癫痫 精神病 Mental Problems Diabetes 糖尿病 Poliomyelitis 小儿麻痹 伤残 Disability Hematologic Diseases 血液病 Frequent Headaches 习惯性头痛 Rheumatic Fever 风湿热 请确认学生是否完成下表所列疫苗 Please indicate if student has received immunizations for the following: Vaccination Date Given (yyyy/mm/dd) Vaccination Date Given (yyyy/mm/dd) Bacillus Chalmette Guerin Vaccine 卡介苗(BCG)

1 Meningococcus Vaccine Men A+C 群流脑疫苗(MA+C)

1 2 Hepatitis B Vaccine 乙肝疫苗(HepB)

1 Japanese Encephalitis Vaccine 乙脑疫苗(日本脑炎)(JE)

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3 Poliomyelitis Vaccine 脊灰疫苗(PV)

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2 Measles 麻疹

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2 4 Measles Mumps Rubella Vaccine 麻腮风(MMR)

1 Diphtheria Pertussis Tetanus Vaccine 百白破疫苗(DPT)

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2 Purified Diphtheria Tetanus Vaccine 精白破(DT)

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2 4 Chicken Pox 水痘

1 Meningococcus Vaccine Men A 群流脑疫苗(MA)

1 Hepatitis A Vaccine 甲肝疫苗

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2 3 Others 其它

4 * 若学生在校突发紧急情况时, 您是否同意由保健室将小孩送至医院? I give permission for my child to be brought to the school'

s Health Office for treatment, then to a hospital if necessary. 愿意 Consent 不愿意 Do Not Consent * 若学生身体情况需转送医院时, 您希望学校将其送至哪家医院;

若无特别指定, 学校将送往浦东儿童医学中心. If your child requires immediate hospitalization, he/she will be sent to the Pudong Children'

s Hospital. If you do not wish for your child to be sent to this hospital, please indicate your preferred hospitals below: 1.2. I hereby give consent for The SMIC Private School and Kindergarten'

s faculty, doctors, and medical staff of the SMIC Clinic to administer first aid to my child in accordance to the terms detailed on this sheet. I will not hold the school and/or any of its representatives responsible for any liability resulting from administration of this first aid by these persons. (Information provided on this form will be kept confidential with homeroom teachers and school doctors only) 我同意,依照上述情况,中芯学校及幼儿园员工、医师、中芯保健中心医护人员可给予我的孩子急救帮助. 对于急救产生的任何后果, 上 述人员将不负任何责任.(以上信息由班主任和医务人员掌握,不对外泄露.) I understand that, if any information I have provided above is found to be inaccurate, I will be held responsible for any consequences. 我承诺:以上提供的资料属实,如有因虚假或隐瞒而造成任何后果,其责任由本人自负. Signature of Guardian 监护人姓名 Relationship to Student 与学生关系 Date 日期 Page

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9 The SMIC PRIVATE SCHOOL 上海市民办中芯学校 Confidential Admissions Survey 入学调查卷 (To be completed by a teacher or administrator of the school that the applicant is attending now) (由现在所读学校老师填写) To the teacher / administrator: The student named below has applied to the SMIC Private School. Please look over this brief questionnaire and answer the below questions. You may return this in a sealed envelope to the parents or send it as a fax to 86-21-