Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
APPLICATION FORM
Please type or write in black ink.
STUDENT INFORMATION
Nickname: _______________________
Family Name (as shown on passport)
First Name
Middle Name
Street Address
City
State/Province
Postal Zone/Code
Country
Home Telephone (with Country/City codes)
Email Address
Fax Number
Emergency Contact Name and Telephone Number
Country of Legal Residence
Nationality on Passport
Passport Number/Expiration Date
Date of Birth (day/month/year)
Age
Grade in School
Birth: City/State or Province/Country
Gender:
_____ Male
_____ Female
Native Language
FAMILY INFORMATION
Father’s Name
Living in Household?
_____Yes
_____ No
_____Yes
_____ No
_____Yes
_____ No
_____Yes
_____ No
Mother’s Name
Sister(s) Name/Age
Brother(s) Name/Age
Religion:
How often do you attend services: _____ weekly _____ monthly _____ occasionally
_____ holidays
Diet: Do you follow a special diet?
_____ Yes
_____ No
If Yes, please indicate: _____ vegetarian _____ vegan
_____ kosher _____ other (please indicate)
Diet: Do you have food allergies?
_____ Yes
_____ No
If Yes, please indicate:
LANUAGES
How many years have you studied English? ____ . Please list other foreign languages and number of years studied:
Do you plan on pursuing a diploma from Green Lake High School? ____ High School diploma ____ IB diploma ___
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SLEP Score: ______________ Date: ______________ TOEFL Score: ______________ Date: ______________
PERSONAL INFORMATION
Indicate the five personality traits which describe you:
_____ Adaptable
_____ Athletic
_____Cheerful
_____Considerate
_____Extroverted
_____Flexible
_____ Friendly
_____ Humorous
_____Independent
_____Informal
_____Intelligent
_____Introverted
_____ Neat
_____ Optimistic
_____Organized
_____Patient
_____Pessimistic
_____Quiet
_____Relaxed
_____ Reliable
_____Reserved
_____Responsible
_____Sensitive
_____Serious
_____Shy
_____ Stubborn
_____Studious
_____Talkative
_____Tolerant
_____Traditional
Indicate your five favorite interests in order of preference by using umbers 1, 2, 3, 4, 5 with 1 being ‘most preferred’:
_____Billiards/Pocket Pool
_____Board Games/Cards
_____Body Building
_____Camping/Backpacking
_____Chess/Backgammon
_____Cinema/Movies
_____Computer
_____Cooking
_____Crafts
_____Dance-Ballet
_____Dance-Modern
_____Dance-Ballroom
_____Discussing Ideas
_____Discussing Politics
_____Drama/Theater
_____Drawing/Painting
_____Gardening
_____Museums/Galleries
_____Music-Classical
_____Music Contemporary
_____Photography/Video
_____ Playing an Instrument
_____Reading
_____Sewing/Needlework
_____Singing
_____Social Dating
_____Stamp/Coin Collecting
_____Watching Television
Other: __________________________________________________________________________________________________
Tell more about the interests you specified above or other interests not indicated above:
Indicate your five favorite sports in order of preference by using 1, 2, 3, 4, 5 with 1 being most preferred:
_____Badminton
_____Baseball
_____Basketball
_____Bicycling
_____Field Hockey
_____Fishing
_____Football (U.S.)
_____Golf
_____Gymnastics
_____Hiking
_____Horseback Riding
_____Hunting
_____Ice Hockey
_____Ice Skating
_____Martial Arts
_____Sailing
_____Roller Skating
_____Snow Skiing
_____Soccer
_____Swimming
_____Tennis
_____Track/Running
_____Volleyball
_____Water Skiing
_____Windsurfing
Tell more about the level of your participation and/or achievements in the sports listed above or list other sports not indicated
above:
Do you hope to participate in sports while participating in the Exchange Program? _____ No _____ Yes
If yes, in what sport(s)
List any musical instruments you play:
I like to meet new people and make many friends:
_____ No _____ Yes
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PERSONAL INFORMATION (continued)
(Feel free to use additional paper)
Describe your hometown:
How does your family spend time together?
What are the family guidelines of your household? What happens when the rules are broken?
What are your household responsibilities at home?
Describe any part-time jobs or work experience you may have had and/or any volunteer activities you have participated
in:
Are you a member of any clubs? If yes, please specify.
What are you most proud of?
Describe your best friend. What qualities make him/her your friend?
How do you deal with peer pressure?
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STUDENT LETTER
This letter is an important part of your application. It is an opportunity for you to introduce yourself to your school. You should
make your letter as friendly and personal as possible. To accomplish this you may want to share your hopes, fears, likes and dislikes,
etc. You should avoid repeating information you have already provided elsewhere in the application. Be creative and let your
personality shine through!
Please note this letter will be distributed with your profile. To ensure the letter’s copy quality, please type or clearly print in black ink.
Your letter is limited to this page. The student letter is to be written by YOU, IN ENGLISH, with no assistance.
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PARENT LETTER
Your letter is an important part of your child’s application. Without repeating any of the information provided elsewhere in this
application, please present more detailed information that will help us understand your child’ personality, interests, life-style, and
habits. We ask that you be frank and honest in this letter and that you comment on your child’s strengths and weaknesses. Please
include the type of information you would want to know if you were going to host or be responsible for someone else’s child.
Please note this letter will be distributed. To ensure the letter’s copy quality please type or clearly print in black ink. You letter is
limited to this page.
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FAMILY ALBUM
On the next two pages, place recent photos showing you, your family, and your friends in the places you frequent, doing
things you enjoy. This photo album is to help us get acquainted with you.
Place a family photo here.
Describe the photo above:
Place a photo of a family activity here.
Describe the photo above:
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Place a photo here that tells something about you.
Describe the photo above:
Place a photo here that tells something about you.
Describe the photo above:
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ENGLISH TEACHER’S RECOMMENDATION
Student’s Full name: ______________________________________________________________________________
Teacher’s full name ________________________________________________ Signature:______________________
School Name ____________________________________________________________________________________
Street address ___________________________________________________________________________________
City ____________________________________ State/Province ______________________ Country _____________
At least one recommendation from an English teacher is required. Additional teacher’s recommendations may be submitted on a
separate sheet, noting the teacher’s school and title (i.e. history teacher) and addressing the questions listed below.
How long have you known the applicant? _____________________________________________________________
Rate the applicant’s written and spoken English proficiency: ______________________________________________
Advanced
Good
Fair
Poor
Reading
________
________
________
________
Writing
________
________
________
________
Speaking
________
________
________
________
Understanding
________
________
________
________
Does the applicant possess the maturity and academic motivation to live and study in the United States for a year?
Please give supporting information on why or why not.
Describe the applicant’s interpersonal skills with peers and teachers.
What are the applicant’s strengths and weaknesses? Please explain in detail.
Please use the other side of this form to provide additional comments that would assist us in evaluating the applicant.
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SECONDARY SCHOOL TRANSCRIPT OF GRADES (Translation)
Please provide, in English, the following information relating to this student’s last four years of school attendance.
Student’s Full name: __________________________________________________Date of Birth ____________________
Citizenship ___________________________________________ Name of School ________________________________
Level presently attending _____________________________________________________________________________
Grading Scale Please list, in English, your grading scale next to the corresponding American Grades listed below.
American
Your Equivalent
Grading Scale
Number or Letter Grade
Comments
Excellent
A
________________
__________________________
Superior
A________________
__________________________
Very Good
B+
________________
__________________________
Good
B
________________
__________________________
Average
C+, C, C________________
__________________________
Poor
D+, D, D________________
__________________________
Fail
F
________________
__________________________
COURSE HISTORY Please list all core and non-core classes below, including all required and elective subjects taken.
Grade in School:
20 - 20
Grade in School:
20 - 20
Course
Grade
Course
Grade
Grade in School:
Course
20 - 20
Grade
Grade in School:
Course
Signature & Seal of School Official
20 - 20
Grade
Date
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Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
Student’s Full Name: ________________________________________________________________________
(Please Print)
LIABILITY RELEASE
We grant the School District of Green Lake and its designated employees where the student will be assigned,
and the Resident Assistant with whom he/she may live that, at their discretion, and if necessary at the cost of
the participant or his/her parents or legal guardians—in the case of expenses exceeding the coverage of the
insurance policy covering the student- the power to place him/her under the care of a local medical doctor for
his/her treatment. We also grant the School District of Green Lake and its designated employees where the
student will be assigned, and the Resident Assistant, all necessary permissions to act as legal guardians and ‘n
loco parentis in any situation, especially in emergencies, whether medical or other, including the possibility of
permission for surgical operations or any other treatment.
We also authorize the School District of Green Lake and its designated employees where the student will be
assigned, and the Resident Assistant to return him/her to his/her country of origin at his/her own cost or that
of his/her parents or legal guardians, if necessary, to submit to medical treatment, if this is deemed necessary
by the above mentioned people, after consultation with medical authorities. We confirm that at the time of
signing this document, the student enjoys perfect health, and that his/her health record enclosed herewith is
true and complete.
We also grant the School District of Green Lake and its designated employees where the student will be
assigned, and the Resident Assistant, permission to act on our behalf in anything pertaining to possible
representation before the local authorities.
This authorization shall be valid for the entire duration of the Green Lake International Student Program in
which the student is participating.
_________________________________________________________
Parent Signature
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____________________________
Date
Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
PROGRAM RULES
Any infraction of the rules will result in immediate dismissal from Green Lake High School and the Green Lake
International Student Program and place your visa in jeopardy:
1. Students must abide by all laws of the United States.
2. It is against the law in the United States for high school students to buy or drink alcohol. This law applies to all
foreign exchange students as well. The legal age for buying and consuming alcohol in the United States is 21.
3. The use of drugs for non-medical reasons by students under any circumstances is strictly forbidden. Some
examples of non-medical (illegal) drugs are cocaine, LSD, methamphetamine, and marijuana.
4. Students are not permitted to hitchhike.
5. Students are not permitted to purchase, carry, or use firearms under any circumstances.
6. Students are not permitted to hold part-time jobs. There are strict rules governing employment for
International Students. A non-immigrant alien who accepts paid employment is subject to deportation. If
students would like to earn spending money during their stay, they are permitted to hold small jobs (no more
than 10 hours per week) such as baby-sitting, grass-cutting, and newspaper delivery.
7. Students are not permitted to drive any motor vehicle (including motorcycles, mopeds, snowmobiles, and cars)
except during the course of an accredited driver education class.
8. The stealing or taking any item or property of others is against the law and is strictly prohibited. (If it does NOT
belong to you leave it alone.)
Any continuous failure to abide by the following rules along with the residence hall and school rules may result in
dismissal from the program and place their Visa in Loss of Status:
1. The legal age for buying cigarettes in the United States is 18. Smoking at school or the residence hall is not
permitted. If you have indicated that you are a non-smoker on your application and you do in fact smoke at your
residence, you will automatically be placed on probation.
2. Students must always be aware of their responsibility as exchange students and as such make a determined
effort to be a positive ambassador for their home country in their school, residence, and host community.
3. Students must attend school daily unless sick and/or under a doctor’s care or with special permission from the
Resident Assistant. Students must complete all homework and assignments.
4. Students must be full time students and maintain a ‘C’ average or better in all classes. Students must also enroll
in an appropriate English language or literature course and an American Social Studies course.
5. Students are not permitted to visit such places as pornographic shops, adult theaters, drinking establishments,
or any web sites related to pornography or gambling.
6. Students must show respect for the Green Lake High School and the Green Lake International Student Program
by participating in scheduled activities. Students are not allowed to stay alone at their residence hall or
Community Connection (host family) homes.
7. Students must abide by all residence hall and Community Connection (host family) residence rules and must
help with residence hall and household chores as assigned.
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8. Students may not change residence hall room assignments at will.
9. Students are allowed to travel only if accompanied by a responsible adult (21 years of age or older) and have
written approval by their natural parents or international agency and have GLISP approval. The trip may not
involve missing any school days (except for school-sponsored trips) without a pre-arranged absence.
Independent travel by participants is not permitted during this program.
10. Students may not have sexual relationships, or sexual contact with others.
11. Students must read the Green Lake International Student Program handbook and agree to abide by the rules,
expectations, regulations, etc. which are contained therein. It is the student’s responsibility to know the rules
outlined herein and within the GLISP handbook. The rules are for the safety and well-being of all students
attending Green Lake High School. Students are expected to cooperate by following these rules. We encourage
students to ask GLHS or GLISP personnel to explain the rules if necessary.
SCHOOL RECORDS
At times throughout the school year, it may be necessary to release school records to other educational institutions or
government agencies. You are agreeing to the authorization to release school records in accordance to school policy.
PROGRAM TERMINATION
GLISP reserves the right to terminate program participation for the violation of any program, residence, local, state,
and/or federal rules and/or when a student’s mental and/or physical health (as determined by a physician or
GLHS/GLISP administration) is in jeopardy. We, the participant and his/her parents, have read and understand all of the
above. As a participant, I agree to obey these rules. I understand that disobeying the rules/regulations will result in my
termination from the program, the loss of full program fees, and I will be returned to my home country at my own
expense.
TRAVEL AUTHORIZATION
We, as parents of the undersigned student, do hereby authorize the Green Lake High School/Green Lake International
Student Program (GLHS/GLISP) Coordinator, and/or Resident Assistant as our agents to determine our student’s travel
for the length of his/her program. It is understood that his/her authorization is given in advance when the student is
traveling and supervised by a Resident Assistant, designated Community Connection parent, or by a representative of a
GLISP school program. We understand and agree that our student may not travel unsupervised, unless we have signed
the Unchaperoned Off-Campus Authorization.
REFUND POLICY
No refunds will be granted if a student transfers an I-20 to another high school or exchange program at his/her own
initiative. In addition, no refunds will be granted should it become necessary to send a student home for rule violations
or behavior issues.
I have read and understand the above information and agree to the terms and conditions set forth. This includes all
information contained within the GLISP Handbook.
Student Signature:______________________________________________________________ Date_________________
Parent Signature: _______________________________________________________________Date_________________
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Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
Student’s Full Name: ________________________________________________________________________
(Please Print)
TRAVEL AUTHORIZATION
We as parents of the undersigned student, do hereby authorize the Green Lake International Student Program
(GLISP) Coordinator, and/or Resident Assistant as our agents to determine the student’s travel for the length
of his/her program. It is understood that his/her authorization is given in advance only when the student is
traveling and supervised by a Resident Assistant, designated host parent or by a representative of a school
program. We understand that the student may not travel unsupervised.
DRIVING
GLISP does not condone the driving of any automobile in the United States of America by its participants,
except as part of an approved Drivers Education and training course. Students can be dismissed from the
GLISP program for a violation of this policy.
Parent’s signature: ___________________________________________________ Date: __________________
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Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
Student’s Full Name: ________________________________________________________________________
(Please Print)
UNCHAPERONED OFF-CAMPUS RULES FOR GLISP STUDENTS
Here at Green Lake High School and Green Lake International Student Program, we care about the safety and
security of our students. Consequently we have established rules and protocols for any unchaperoned offcampus activities.
If a student wishes to go off-campus without an approved adult chaperone, the student must:
1.
2.
3.
4.
Obtain permission from a Resident Assistant and sign out at the residence hall.
Indicate destination and return time.
Be accompanied by a ‘buddy’.
Have a cell phone.
When a student requests to go off campus, the student must have the following information ready:
1. The name of a buddy.
2. Specific destination (store, restaurant, sport event, etc.)
3. If the destination is a friend’s home, must have friend’s full name, parent’s full name or name of
adult chaperone who will be present, and phone number (Resident Assistant may call to verify),
nature of the visit (hanging out party, lunch, etc.)
4. If destination involves riding in a car, driver’s name, age, car license number, parent’s name and
phone number (Resident Assistant may call to verify), other passengers in the car.
5. Intended return time; If late, must notify Resident Assistant.
6. Student’s cell phone number.
The following activities are strictly forbidden: Hitchhiking; driving or operating a motorized vehicle (including
motorcycles, mopeds, four wheelers, snowmobiles, and cars; shoplifting or stealing (taking another person’s
property); vandalism (including destroying property, graffiti or other destructive behavior); alcohol or drugs;
and any other activities deemed inappropriate by GLISP staff.
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Any infraction of the rules above will result in the loss of off campus privileges for a minimum of one week.
Subsequent violations will be cause for further restrictions, up to and including dismissal from the Green Lake
International Student Program.
PROGRAM TERMINATION
GLISP reserves the right to terminate program participation for the violation of any program, residence, local,
state, and/or federal rules and/or when a student’s mental and/or physical health (as determined by a
physician or GLISP administration) is in jeopardy. Incidents of inappropriate conduct or inappropriate public
display will be investigated by GLISP personnel and may lead to disciplinary actions.
As the participant, I have read and understand all of the above and I agree to obey these rules. I understand
that disobeying any rules or laws will result in my termination from the program, loss of full program fees and
the possible return to my home country at my own expense.
I have read and understand the above information and agree to the terms and conditions set forth,
including all information contained within the GLISP Handbook.
Student Name (Please print): _________________________________________________________________
Student Signature: _________________________________________________ Date: ___________________
I have read and understand the above information and agree to the terms and conditions set forth,
including all information contained within the GLISP Handbook. I authorize my student to take part in the
Unchaperoned Off-Campus Rules for GLISP Students.
Parent/Guardian Name (Please print): __________________________________________________________
Parent Signature: __________________________________________________ Date: ____________________
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Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
SCHOOL DISTRICT OF GREEN LAKE
PERMISSION FORM FOR WORLD WIDE WEB (INTERNET) PUBISHING
OF STUDENT WORK OR PHOTOGRAPH.
_____ Student Work (Please initial)
We understand that our student’s academic work or writing may be considered for publication on the World
Wide Web, a part of the Internet. We further understand that any student work will appear with a copyright notice
prohibiting the copying of such work without express written permission. In the event anyone requests such permission,
those requests will be forwarded to us. No home address or telephone number will appear with such work. Only the
student’s first name will be used when publishing work.
_____ Student Photograph (Please initial)
We understand that our student’s photograph may be considered for publication on the World Wide Web, a
part of the Internet. If a photo of the student is used, the first name only will appear with the picture. This includes any
team or club pictures.
We grant permission for the World Wide Web publishing as described and initialed above until the end of the 2013-2014
school year. Such permission releases the School District of Green Lake, School Board, or employees from any and all
liability and legal or equitable claims related to student work being published on the district web site.
Parent/Guardian Name (Please print): __________________________________________________________________
Parent Signature: _________________________________________________________ Date: ____________________
I, the student, also give my permission for such publishing.
Student Name (Please print): __________________________________________________________________________
Student Signature: __________________________________________________________ Date: ___________________
We DO NOT grant permission for the World Wide Web publishing as described above.
Parent/Guardian Name (Please print): __________________________________________________________________
Parent Signature: _________________________________________________________ Date: ____________________
Student Name (Please print): __________________________________________________________________________
Student Signature: __________________________________________________________ Date: ___________________
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Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
January 2014
Dear Parent/Guardian,
The School District of Green Lake takes great pride in making sure your son/daughter receives quality medical
care while attending school. We have a Medical Advisor who is available for consultation at any time in the
event we have health concerns during the course of the school year. Please note on your application if your
son/daughter has any health related issues we should be aware of.
Also included in the application process is the State of Wisconsin Student Immunization Law Age/Grade
Requirements for the 2013-2014 school year. The State of Wisconsin requires strict compliance for students
attending Wisconsin schools. Please read these forms closely and complete them accordingly. Be sure to
document all immunizations. You may waiver the required immunizations due to health, religious, or
personal convictions. If you choose the waiver, this needs to be indicated on the Student immunization Record
in Step 4 and your signature/date in Step 5.
At this time the School District of Green Lake will not administer any medications brought to the United States
by your child due to school policy. Unfortunately, many non-prescription and prescription medications
brought by international students are unable to be read as they are written in the student’s native language.
Obviously, this prevents us from knowing what the medication is used for and the proper dosage to be given.
All prescription drugs MUST BE IDENTIFIED AND WRITTEN IN ENGLISH INCLUDING THE DOSAGE. The Standing
Orders allow us to administer medications to your son or daughter if they present any of these symptoms
listed on the attached Standing Orders for Administration of Medication. All these medications are over the
counter non-prescription medications. We have included various health needs common to the American
school-age population. If there are other health concerns the district nurse will refer your son or daughter to
a health care provider in the Green Lake area. Please review the attached Standing Orders. If you agree that
your son or daughter may receive any of these medications during the course of the school year, please sign
and date at the bottom of the Standing Orders sheet.
The School District of Green Lake works closely with area medical clinics. In the event your son/daughter
needs immediate care or evaluation, we will have them seen by a physician. The Release of Information
Authorization and Consent for Treatment of Minors in Parent/Legal Guardian Absence form is needed for the
School District of Green Lake to seek treatment for your child. Please sign and date the form.
All medical forms need a parent/guardian signature along with a date in order for the forms to be valid. If you
have any questions, please feel free to contact me.
Thank you,
Morna Helbach, GLISP Coordinator
mhelbach@glsd.k12.wi.us
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Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
STANDING ORDERS FOR MEDICATION ADMINISTRATION 2013-2014
Allergies
Loratadine (Claritin) 10mg 1 tablet daily for sneezing and runny nose.
Benadryl 25mg 1-2 capsules every 6-8 hours as necessary for sneezing and runny nose.
Cold & Congestion
Decongestant Pseudoephedrine 30mg 1 tablet every 4-6 hours.
PRN for nasal congestion.
Car Sickness
Dramamine 1 tablet every 8 hours (should be administered prior to a long bus ride/car
ride.)
Constipation
MiraLax 1 cap full in 8 ounces of clear liquids daily.
Cough
Robitussin (generic dextromethorphan) 2 teaspoons (10cc) every 4-6 hours as necessary
for cough. Cough drop 1 every 2-3 hours.
Cuts/Abrasions/
Scrapes/Burns
Triple Antibiotic Ointment 2-3 times per day or as needed; cover with a band-aid and
assess for infection.
Diarrhea
Imodium 2 tablets following the 1st loose stool; 1 tablet every 8 hours as needed.
Digestion/Gas/
Tums 2 chewable tablets every 4 hours as necessary for upset stomach & heartburn.
Stomach Discomfort
Eye Irritation
Artificial Tears 2-3 drops to each eye as needed.
Fever
Tylenol Extra Strength 2 tablets every 4 hours for fever.
Headaches
Ibuprofen 200mg 2 tablets every 4-6 hours (should not be given on an empty stomach)
or Tylenol 500mg 1-2 tablets every 4-6 hours.
Menstrual Cramps
Ibuprofen 200 mg 2-3 tablets every 4-6 hours as necessary for menstrual cramps (should
not be administered on an empty stomach).
Pain/Aches/
Acetaminophen (Tylenol) 500mg 1-2 tablets every 4-6 hours; 1% Hydrocortisone Cream
General Discomfort topically 3-4 times daily.
____________________________________________
Parent/Legal Guardian Signature
______________________________
Date
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Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
MEDICAL RELEASE AUTHORIZATION
We, as parents/guardians of the undersigned student, hereby authorize the Resident Assistant or school
official to consent to any medical diagnosis, treatment or care which a licenses doctor or hospital deems to be
medically necessary for our son/daughter while he/she is participating in this exchange program.
In addition, we authorize Green Lake International Student Program and Green Lake High School to provide
my child with a physical examination for the purposes of participating in school sponsored athletics.
It is understood that this authorization is not given in advance of any specific diagnosis, treatment or hospital
care being required, but is given to provide authority and power on the part of the host Resident Assistant or
school official to give specific consent to any and all such diagnosis, treatment or hospital care which the
aforementioned physician or surgeon in the exercise of his/her best judgment may deem advisable. The
medical expenses will be assumed by the student’s legal parents/guardians.
Parent/Guardian Name (Please print): ___________________________________________________________
Parent Signature: __________________________________________________ Date: ____________________
Student Name (Please print): _________________________________________________________________
Student Signature: _________________________________________________ Date: ___________________
MEDICAL INSURANCE INFORMATION:
Name of Company __________________________________________________________________________
Phone Number: ____________________________________________________________________________
Policy Number: ____________________________________________________________________________
Insurance Contact Information: _______________________________________________________________
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STATEMENT OF APPLICANT’S HEALTH
GREEN LAKE INTERNATIONAL STUDENT PROGRAM
Must be completed by attending physician who is not related to student.
Student’s Full Name _________________________________________________________________________________
Address ___________________________________________________________________________________________
Has the applicant ever had any of the following:
Any disease, impairment of abnormality of:
Yes
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Yes
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
No
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
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Yes
Allergies to Drugs _____
Food Allergies
_____
Smoke Allergies
_____
Pet Allergies
_____
Asthma
_____
Appendicitis
_____
Cough (persistent) _____
Diabetes Mellitus _____
Enuresis
_____
Goiter
_____
Migraine Headache _____
Speech Defect
_____
Parasites(intestinal)_____
No
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Measles (Rubeola)
Chicken Pox
Rheumatic Fever
Rubella
Scarlet Fever
Hepatitis A
Hepatitis B
Hernia
Malaria
Seizure Disorder
Sleepwalking
Eating Disorder
Vertigo, Dizziness
No
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Abdominal Organs/Digestive System
Bones, Joints, Motor System
Blood, Endocrine System
Tonsils, Nose or Throat
Varicose Veins
Brain, Nervous System
Ears or Hearing
Eyes or Vision
Genito-Urinary System
Heart or Blood Vessels
Lungs, Respiratory System
Skin (Acne, etc.)
TBC – Tuberculosis
If ‘Yes’ was checked for any of the above, physician must provide IN ENGLISH full details and dates of treatment.
Has applicant ever been hospitalized? _____ Yes
_____ No. If yes, please provide details and dates:
Has applicant ever been advised to have surgery which has not been done? _____ Yes _____ No. If yes, please explain:
Is applicant presently taking any medication or injections? _____ Yes _____ No. If yes, please explain:
Will the applicant bring to the United States, or receive from home, any regularly used medications? _____ Yes _____ No.
If yes, what are these medications?
What is the purpose of the use of the medications?
Has applicant ever consulted a psychologist, psychiatrist, neurologist or any other specialist for an eating disorder (anorexia nervosa,
bulimia, etc.? _____ Yes _____ No If yes, please explain:
Has applicant ever consulted a psychologist, psychiatrist, neurologist or any other specialist for sexual, emotional or physical abuse?
_____ Yes _____ No If yes, please explain.
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Please provide figures for the following:
Blood Type: _____________________ Height: _______________ Weight: ________________ Blood Pressure: _________________
Urinalysis Specific Gravity: _______________________________ Alb: __________________ Sugar: _________________________
Vision without Glasses: OD ______________ OS ______________ Vision with Glasses OD _______________ OS _______________
Are papillary and knee reflexes normal? _____ Yes _____ No
If no, please explain:
Does student have any scars or identifying narks? _____ 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:
Detail any disease, impairment or abnormality not fully explained on either side of this form:
Has student ever received BCG vaccine? _____ Yes _____ No
If yes please provide date and sign the confirmation below that the student is free of TB: _____/_____/__________
My patient, _______________________________________ is free of TB. Doctor’s Signature: _______________________________
If no, student must have had a TB test within the past year: Date of test: _____/_____/__________
Tuberculin Skin test: _____ + _____ If positive report of negative x-ray and copy required:
Type of test: _____ PPD _____ Mantoux
Chest x-ray + Date of x-ray _____/_____/__________
Has student ever received Hepatitis A vaccine? _____ Yes _____ No
If yes, please give dates of vaccinations: 1st dose: _____/_____/_____ 2nd dose: _____/_____/_____ 3rd dose: _____/_____/_____
Has student ever received Hepatitis B vaccine? _____ Yes _____ No
If yes, please give dates of vaccinations: 1st dose: _____/_____/_____ 2nd dose: _____/_____/_____ 3rd dose: _____/_____/_____
The following question is for informational purposes only and may become a requirement upon student’s placement. Has student
ever received Varicella (chicken pox) vaccine? _____ Yes _____ No If yes, please give date of vaccinations: _____/_____/_____
IN ADDITION, PLEASE COMPLETE IMMUNIZATION RECORD FORM
Your opinion of the state of the candidate’s health: _____ Excellent
_____ Good
_____ Fair
_____ Poor
I, the undersigned, have reviewed the medical history of the applicant and given a thorough physical examination and certify that all
important medical information has been noted on this form and that nothing relevant has been omitted.
The student is physically fit enough to participate in a school sport activity if the student chooses to do so.
Physician’s Signature____________________________________________ Name (Print) ___________________________________
Address___________________________________________________________________ Date _____________________________
Please affix seal, stamp, or provide medical license number for verification purposes.
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Green Lake International Student Program
Green Lake High School
Green Lake, Wisconsin, USA
Consent for Treatment of Minors in Parent/Legal Guardian Absence
To comply with Wisconsin law, a medical clinic requires that a parent (not step-parent/foster parent) or legal
guardian (guardian appointed by a court) consent to the care of minor children. In the event that a parent or
legal guardian is unable to consent to care the parent or legal guardian may delegate the right to consent to
another adult. In the event that a minor child presents for a non-urgent medical/behavioral health/dental
appointment without a parent or legal guardian or a signed consent, treatment may be denied.
I/We (parent’s name) _______________________________________________________________ authorize
the School District of Green Lake/Green Lake International Student Program and its designee to consent to:
___ Emergency or urgent care at nearest facility when I cannot be reached.
___ Medical and dental care including immunizations, lab work and other diagnostic tests, but not including
any surgery or other procedures which require anesthesia, except for a local anesthetic.
___Any and all necessary medical/dental and surgical care and treatment at nearest facility for my child:
Child’s name________________________________________ Child’s MHN _____________________
during the period:
___ Date (month/day/year) ________ /________ /________ to ________ /________ /________
___ For a maximum period of 1 year
___ Medical clinic providers should attempt to contact me before providing care at the following numbers:
Home phone ___________________Work phone ___________________ Cell phone _____________________
I further agree to reimburse the medical clinic/health care provider for the cost of rendering these services
to the extent that my insurance does not pay for these services.
______________________________________________
______________________________
Patient signature (person authorized to consent for patient) (relationship)
_____________________________________________________________ __________________________
Child’s parent/legal guardian, address
Date (month/day/year)
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