%PDF-1.6
%
1 0 obj
<>
endobj
2 0 obj
<>stream
2022-08-01T15:49:23-06:00
2022-08-01T15:49:23-06:00
2022-08-01T15:49:23-06:00
Chrome
application/pdf
admission forms - updated 8_1_22 - Google Docs
uuid:70c1e404-7acd-b748-bb8c-4b4b40cf5ed1
uuid:84a3f19c-5954-7647-a9ec-8a95b3a0fc70
Adobe Mac PDF Plug-in
endstream
endobj
3 0 obj
<>
endobj
5 0 obj
<>/ExtGState<>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/Type/Page>>
endobj
6 0 obj
<>stream
/CS0 cs 1 1 1 scn
/GS0 gs
0 0 612 792 re
f
0 0.75 612 791.25 re
f
BT
0 0 0 scn
/TT0 1 Tf
13.995 0 0 13.995 72 733.56 Tm
( )Tj
T*
(A)Tj
(D)Tj
(M)Tj
(I)Tj
(N)Tj
(I)Tj
(S)Tj
(T)Tj
(R)Tj
(A)Tj
6.203 0 Td
(T)Tj
(I)Tj
(O)Tj
(N)Tj
( )Tj
(O)Tj
(F)Tj
( )Tj
(M)Tj
(E)Tj
(D)Tj
(I)Tj
(C)Tj
(A)Tj
8.203 0 Td
(T)Tj
(I)Tj
(O)Tj
(N)Tj
( )Tj
(T)Tj
3.259 0 Td
(O)Tj
( )Tj
(S)Tj
(T)Tj
(U)Tj
(D)Tj
(E)Tj
(N)Tj
(T)Tj
(S)Tj
( )Tj
-17.666 -1.179 Td
( )Tj
T*
(P)Tj
(H)Tj
(Y)Tj
(S)Tj
(I)Tj
(C)Tj
(I)Tj
(A)Tj
(N)Tj
(\222)Tj
(S)Tj
( )Tj
(R)Tj
(E)Tj
(Q)Tj
(U)Tj
(E)Tj
(S)Tj
(T)Tj
( )Tj
(F)Tj
(O)Tj
(R)Tj
( )Tj
(A)Tj
(D)Tj
(M)Tj
(I)Tj
(N)Tj
(I)Tj
(S)Tj
(T)Tj
(R)Tj
(A)Tj
20.372 0 Td
(T)Tj
(I)Tj
(O)Tj
(N)Tj
( )Tj
(O)Tj
(F)Tj
( )Tj
(P)Tj
(R)Tj
(E)Tj
(S)Tj
(C)Tj
(R)Tj
(I)Tj
(P)Tj
(T)Tj
(I)Tj
(O)Tj
(N)Tj
( )Tj
-20.372 -1.179 Td
( )Tj
T*
(M)Tj
(E)Tj
(D)Tj
(I)Tj
(C)Tj
(A)Tj
3.87 0 Td
(T)Tj
(I)Tj
(O)Tj
(N)Tj
(S)Tj
( )Tj
(B)Tj
(Y)Tj
( )Tj
(S)Tj
(C)Tj
(H)Tj
(O)Tj
(O)Tj
(L)Tj
( )Tj
(P)Tj
(E)Tj
(R)Tj
(S)Tj
(O)Tj
(N)Tj
(N)Tj
(E)Tj
(L)Tj
( )Tj
/TT1 1 Tf
10.995 0 0 10.995 72 671.73 Tm
( )Tj
T*
(D)Tj
(A)Tj
1.315 0 Td
(T)Tj
(E)Tj
(:)Tj
( )Tj
-1.315 -2.592 Td
( )Tj
T*
(S)Tj
(T)Tj
(U)Tj
(D)Tj
(E)Tj
(N)Tj
(T)Tj
(\222)Tj
(S)Tj
( )Tj
(F)Tj
(U)Tj
(L)Tj
(L)Tj
( )Tj
(N)Tj
(A)Tj
(M)Tj
(E)Tj
(:)Tj
( )Tj
0 -1.209 Td
( )Tj
T*
(i)Tj
(s)Tj
( )Tj
(u)Tj
(n)Tj
(d)Tj
(e)Tj
(r)Tj
( )Tj
(m)Tj
(y)Tj
( )Tj
(c)Tj
(a)Tj
(r)Tj
(e)Tj
( )Tj
(a)Tj
(n)Tj
(d)Tj
( )Tj
(m)Tj
(u)Tj
(s)Tj
(t)Tj
( )Tj
(t)Tj
(a)Tj
(k)Tj
(e)Tj
( )Tj
(m)Tj
(e)Tj
(d)Tj
(i)Tj
(c)Tj
(a)Tj
(t)Tj
(i)Tj
(o)Tj
(n)Tj
( )Tj
(w)Tj
(h)Tj
(i)Tj
(c)Tj
(h)Tj
( )Tj
(I)Tj
( )Tj
(h)Tj
(a)Tj
(v)Tj
(e)Tj
( )Tj
(p)Tj
(r)Tj
(e)Tj
(s)Tj
(c)Tj
(r)Tj
(i)Tj
(b)Tj
(e)Tj
(d)Tj
( )Tj
(d)Tj
(u)Tj
(r)Tj
(i)Tj
(n)Tj
(g)Tj
( )Tj
(t)Tj
(h)Tj
(e)Tj
( )Tj
(s)Tj
(c)Tj
(h)Tj
(o)Tj
(o)Tj
(l)Tj
( )Tj
(d)Tj
(a)Tj
(y)Tj
39.558 0 Td
(.)Tj
( )Tj
-39.558 -2.456 Td
( )Tj
T*
(N)Tj
(A)Tj
(M)Tj
(E)Tj
( )Tj
(O)Tj
(F)Tj
( )Tj
(M)Tj
(E)Tj
(D)Tj
(I)Tj
(C)Tj
(A)Tj
8.648 0 Td
(T)Tj
(I)Tj
(O)Tj
(N)Tj
( )Tj
(\()Tj
(a)Tj
(s)Tj
( )Tj
(i)Tj
(t)Tj
( )Tj
(a)Tj
(p)Tj
(p)Tj
(e)Tj
(a)Tj
(r)Tj
(s)Tj
( )Tj
(o)Tj
(n)Tj
( )Tj
(c)Tj
(o)Tj
(n)Tj
(t)Tj
(a)Tj
(i)Tj
(n)Tj
(e)Tj
(r)Tj
( )Tj
(i)Tj
(n)Tj
( )Tj
(w)Tj
(h)Tj
(i)Tj
(c)Tj
(h)Tj
( )Tj
(t)Tj
(h)Tj
(e)Tj
( )Tj
(d)Tj
(r)Tj
(u)Tj
(g)Tj
( )Tj
(i)Tj
(s)Tj
( )Tj
(s)Tj
(t)Tj
(o)Tj
(r)Tj
(e)Tj
(d)Tj
(\))Tj
(:)Tj
( )Tj
-8.648 -3.839 Td
( )Tj
T*
(D)Tj
(O)Tj
(S)Tj
(A)Tj
(G)Tj
(E)Tj
( )Tj
(&)Tj
( )Tj
(T)Tj
(I)Tj
(M)Tj
(E)Tj
(\()Tj
(S)Tj
(\))Tj
(:)Tj
( )Tj
0 -2.592 Td
( )Tj
T*
(B)Tj
(E)Tj
(G)Tj
(I)Tj
(N)Tj
( )Tj
(D)Tj
(A)Tj
4.705 0 Td
(T)Tj
(E)Tj
(:)Tj
( )Tj
-4.705 -2.505 Td
( )Tj
T*
(P)Tj
(O)Tj
(S)Tj
(S)Tj
(I)Tj
(B)Tj
(L)Tj
(E)Tj
( )Tj
(A)Tj
(D)Tj
(V)Tj
(E)Tj
(R)Tj
(S)Tj
(E)Tj
( )Tj
(R)Tj
(E)Tj
(A)Tj
(C)Tj
(T)Tj
(I)Tj
(O)Tj
(N)Tj
(S)Tj
( )Tj
(T)Tj
16.986 0 Td
(O)Tj
( )Tj
(B)Tj
(E)Tj
( )Tj
(R)Tj
(E)Tj
(P)Tj
(O)Tj
(R)Tj
6.206 0 Td
(T)Tj
ET
BT
10.995 0 0 10.995 333.7108 504.69 Tm
(E)Tj
(D)Tj
( )Tj
(T)Tj
2.26 0 Td
(O)Tj
( )Tj
(T)Tj
(H)Tj
(E)Tj
( )Tj
(P)Tj
(H)Tj
(Y)Tj
(S)Tj
(I)Tj
(C)Tj
(I)Tj
(A)Tj
(N)Tj
(:)Tj
( )Tj
-26.062 -3.752 Td
( )Tj
T*
(S)Tj
(P)Tj
(E)Tj
(C)Tj
(I)Tj
(A)Tj
(L)Tj
( )Tj
(I)Tj
(N)Tj
(S)Tj
(T)Tj
(R)Tj
(U)Tj
(C)Tj
(T)Tj
(I)Tj
(O)Tj
(N)Tj
(S)Tj
( )Tj
(F)Tj
(O)Tj
(R)Tj
( )Tj
(A)Tj
(D)Tj
(M)Tj
(I)Tj
(N)Tj
(I)Tj
(S)Tj
(T)Tj
(R)Tj
(A)Tj
20.761 0 Td
(T)Tj
(I)Tj
(O)Tj
(N)Tj
( )Tj
(O)Tj
(R)Tj
( )Tj
(D)Tj
(O)Tj
(S)Tj
(A)Tj
(G)Tj
(E)Tj
( )Tj
(O)Tj
(F)Tj
( )Tj
(D)Tj
(R)Tj
(U)Tj
(G)Tj
(:)Tj
( )Tj
/CS1 cs 0 scn
/TT2 1 Tf
12 0 0 12 72 421.23 Tm
( )Tj
T*
(I)Tj
( )Tj
0.681 0 Td
( )Tj
T*
(or)Tj
( )Tj
1.292 0 Td
( )Tj
T*
(my)Tj
( )Tj
1.736 0 Td
( )Tj
T*
(designee\(s\))Tj
( )Tj
5.628 0 Td
( )Tj
T*
(have)Tj
( )Tj
2.571 0 Td
( )Tj
T*
(trained)Tj
( )Tj
3.46 0 Td
( )Tj
T*
(school)Tj
( )Tj
3.293 0 Td
( )Tj
T*
(personnel)Tj
( )Tj
4.795 0 Td
( )Tj
T*
(or)Tj
( )Tj
1.292 0 Td
( )Tj
T*
(approved)Tj
( )Tj
4.573 0 Td
( )Tj
T*
(alternative)Tj
( )Tj
4.954 0 Td
( )Tj
T*
(training)Tj
( )Tj
3.62 0 Td
( )Tj
T*
(as)Tj
( )Tj
-37.896 -1.187 Td
( )Tj
T*
(adequate)Tj
4.171 0 Td
( )Tj
0.653 0 Td
( )Tj
T*
(to)Tj
( )Tj
1.487 0 Td
( )Tj
T*
(administer)Tj
( )Tj
5.266 0 Td
( )Tj
T*
(the)Tj
( )Tj
2.043 0 Td
( )Tj
T*
(medication,)Tj
( )Tj
5.767 0 Td
( )Tj
T*
(have)Tj
( )Tj
2.759 0 Td
( )Tj
T*
(evaluated)Tj
( )Tj
4.927 0 Td
( )Tj
T*
(the)Tj
( )Tj
1.98 0 Td
( )Tj
T*
(situation,)Tj
( )Tj
4.593 0 Td
( )Tj
T*
(the)Tj
( )Tj
1.98 0 Td
( )Tj
T*
(general)Tj
( )Tj
-35.625 -1.187 Td
( )Tj
T*
(administration)Tj
( )Tj
6.69 0 Td
( )Tj
T*
(plan)Tj
( )Tj
2.356 0 Td
( )Tj
T*
(and)Tj
( )Tj
2.134 0 Td
( )Tj
T*
(if)Tj
( )Tj
0.965 0 Td
( )Tj
T*
(applicable,)Tj
4.781 0 Td
( )Tj
0.465 0 Td
( )Tj
T*
(the)Tj
( )Tj
1.855 0 Td
( )Tj
T*
(self)Tj
( )Tj
2.021 0 Td
( )Tj
T*
(administration)Tj
( )Tj
6.69 0 Td
( )Tj
T*
(plan)Tj
( )Tj
2.356 0 Td
( )Tj
T*
(or)Tj
( )Tj
1.354 0 Td
( )Tj
T*
(emergency)Tj
( )Tj
5.35 0 Td
( )Tj
T*
(care)Tj
( )Tj
-37.02 -1.187 Td
( )Tj
T*
(plan,)Tj
( )Tj
2.509 0 Td
( )Tj
T*
(and)Tj
( )Tj
2.009 0 Td
( )Tj
T*
(deemed)Tj
( )Tj
3.954 0 Td
( )Tj
T*
(each)Tj
( )Tj
2.509 0 Td
( )Tj
T*
(to)Tj
( )Tj
1.174 0 Td
( )Tj
T*
(be)Tj
( )Tj
1.453 0 Td
( )Tj
T*
(safe)Tj
( )Tj
2.23 0 Td
( )Tj
T*
(and)Tj
( )Tj
2.009 0 Td
( )Tj
T*
(appropriate,)Tj
5.337 0 Td
( )Tj
0.34 0 Td
( )Tj
T*
(and)Tj
( )Tj
2.009 0 Td
( )Tj
T*
(if)Tj
( )Tj
0.84 0 Td
( )Tj
T*
(applicable)Tj
( )Tj
4.844 0 Td
( )Tj
T*
(authorize)Tj
( )Tj
4.454 0 Td
( )Tj
T*
(the)Tj
( )Tj
( )Tj
1.668 0 Td
(use)Tj
( )Tj
-37.339 -1.187 Td
( )Tj
T*
(of hypodermic syringes and needles or similar medical terms.)Tj
27.122 0 Td
( )Tj
-27.122 -4.75 Td
( )Tj
T*
(_____________________________________________________________)Tj
33.925 0 Td
( )Tj
-33.925 -1.187 Td
( )Tj
T*
(Name of Physician and Designee - Print or T)Tj
19.731 0 Td
(ype)Tj
( )Tj
-19.731 -2.375 Td
( )Tj
T*
(_____________________________________________________________)Tj
33.925 0 Td
( )Tj
-33.925 -1.187 Td
( )Tj
T*
(Primary Phone Number)Tj
( )Tj
0 -2.375 Td
( )Tj
T*
(_____________________________________________________________)Tj
33.925 0 Td
( )Tj
-33.925 -1.187 Td
( )Tj
T*
(Secondary Phone Number)Tj
11.785 0 Td
( )Tj
-11.785 -2.375 Td
( )Tj
T*
(_____________________________________________________________)Tj
33.925 0 Td
( )Tj
-33.925 -1.187 Td
( )Tj
T*
(Signature of Physician)Tj
( )Tj
ET
0.75 w
q 1 0 0 1 103.5 670.875 cm
0 0 m
4.5 0 l
S
Q
q 1 0 0 1 108 670.125 cm
0 0 m
108 0 l
S
Q
q 1 0 0 1 201.75 641.625 cm
0 0 m
338.25 0 l
S
Q
q 1 0 0 1 72 586.875 cm
0 0 m
468 0 l
S
Q
q 1 0 0 1 176.25 559.125 cm
0 0 m
363.75 0 l
S
Q
q 1 0 0 1 141 530.625 cm
0 0 m
399 0 l
S
Q
q 1 0 0 1 72 490.125 cm
0 0 m
468 0 l
S
Q
q 1 0 0 1 72 448.875 cm
0 0 m
468 0 l
S
Q
endstream
endobj
10 0 obj
<>
endobj
11 0 obj
<>
endobj
12 0 obj
<>
endobj
17 0 obj
<>
endobj
18 0 obj
<>stream
H\n@<C !KH>ֻa ŀ0>wZ!t}7440SS ]dkfZ~K=&i\|_p!*7twv8$1a{=
|M8.7+
endstream
endobj
19 0 obj
<>stream
HUtMW7