ࡱ>  _bjbj$$ NF|F|=vv8DhzDT*4***$3 >Cfffffff$kmnfqWH2$3WHWHf**HhPPPWH**fPWHfPPQa|b*P[@Haf^h0ha(nIh(n$b(nbFLG6P>G,jGFFFffN*FFFhWHWHWHWH(nFFFFFFFFFv :  Parent Form DIABETES MEDICAL MANAGEMENT PLAN This form must be renewed each school year or with any change in treatment plan Students Name: FORMTEXT      Date of Birth: FORMTEXT       PARENT CONSENT FOR DIABETES MEDICAL MANAGEMENT PLAN We (I), the undersigned, the parent(s)/guardian(s) of the above named child, request that this Diabetes Medical Management Plan, and any modification thereto, be implemented while our (my) child is at school or attending a school-related event on or off campus. We (I) understand that the services will be administered to our (my) child in accordance with Education Code section 49423.5. We (I) understand that specialized physical health care services may be performed/monitored by unlicensed designated school personnel under the training and supervision provided by a credentialed school nurse. We (I) agree to: Provide the necessary supplies, snacks, medications, and equipment. Notify the school nurse if there is a change in pupil health status or attending physician. Notify the school nurse immediately and provide new written consent for any changes to this order form. We (I) understand that we (I) will be provided with a copy of our (my) childs completed Diabetes Medical Management Plan. We (I) authorize the school nurse to communicate with the physician when necessary. We (I) also consent to the release of information contained in the Diabetes Medical Management Plan to the  FORMTEXT      School District staff and other adults who have custodial care of our (my) child and who may need to know this information to maintain our (my) child s health and safety. This consent also extends to other adults who may need to know the information contained in this Diabetes Medical Management Plan to maintain our (my) childs health and safety. We (I) understand that any written parent/guardian consent for modifications that require physician authorization, as noted above, will not be implemented unless written physician authorization is also submitted to school personnel. All modifications to the Diabetes Medical Management Plan MUST be in written form. The requests for modification received in writing must include the date, the modification, and signatures of both the parent/guardian and the school employee receiving the modification, and a written physician authorization if required. These changes will be attached to his/her Diabetes Medical Management Plan and will be maintained in the students health record.  FORMTEXT       FORMTEXT      Student s Parent/Guardian (please print)Student s Parent/Guardian (signature)Date FORMTEXT       FORMTEXT      Student s Parent/Guardian (please print)Student s Parent/Guardian (signature)DateReviewed by School Nurse FORMTEXT      (signature)DateReviewed by Principal FORMTEXT      (signature)Date  Parent Form DIABETES MEDICAL MANAGEMENT PLAN This form must be renewed each school year or with any change in treatment plan Contact Information Student s Name: FORMTEXT      Date of Birth: FORMTEXT      School Name: FORMTEXT      Grade: FORMTEXT      Teacher: FORMTEXT      Mother/Guardian: FORMTEXT      Father/Guardian: FORMTEXT      Telephone: Home( FORMTEXT      )  FORMTEXT       Telephone:Home( FORMTEXT      )  FORMTEXT        Work( FORMTEXT      )  FORMTEXT       Work( FORMTEXT      )  FORMTEXT        Cell( FORMTEXT      )  FORMTEXT       Cell( FORMTEXT      )  FORMTEXT       Address: FORMTEXT      Address: FORMTEXT       FORMTEXT       FORMTEXT      Student s Primary Care ProviderName: FORMTEXT      Address: FORMTEXT       FORMTEXT       FORMTEXT      StreetCityZipTelephone:( FORMTEXT      )  FORMTEXT       Emergency Number:( FORMTEXT      )  FORMTEXT       Student s Pediatric Endocrinologist (3 to 4 visits are recommended each year)Name: FORMTEXT      Address: FORMTEXT       FORMTEXT       FORMTEXT      StreetCityZipTelephone:( FORMTEXT      )  FORMTEXT       Emergency Number:( FORMTEXT      )  FORMTEXT       Additional Emergency Contact:Name: FORMTEXT      Relationship: FORMTEXT      Telephone:Home( FORMTEXT      )  FORMTEXT       Work( FORMTEXT      )  FORMTEXT       Cell( FORMTEXT      )  FORMTEXT         Physician Form DIABETES MEDICAL MANAGEMENT PLAN This form must be renewed each school year or with any change in treatment plan Student s Name:  FORMTEXT      Date of Birth: FORMTEXT       Physical Condition:  FORMCHECKBOX  Type 1 Diabetes FORMCHECKBOX  Type 2 DiabetesDate of Diagnosis: FORMTEXT      The Effective Date of this Plan is from: FORMTEXT      until the end of the school year. Medications Taken at Home Insulin MedicationOral MedicationPre-Breakfast: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      MedicationAmountTimeMedicationAmountTimePre-Bedtime FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      MedicationAmountTimeMedicationAmountTimeOther FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Medication AmountTimeMedicationAmountTime Snacks Ordered for School SnackTimeFood Content/AmountMid-Morning Snack FORMTEXT       FORMTEXT      Mid-Afternoon Snack FORMTEXT       FORMTEXT      Other times to give snacks FORMTEXT       FORMTEXT      Snack before exercise  FORMCHECKBOX  Yes  FORMCHECKBOX  NoSnack after exercise  FORMCHECKBOX  Yes  FORMCHECKBOX  NoPreferred snack foods: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Foods to avoid, if any: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Instructions when food is provided to the class (e.g., class parties): FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Exercise and Sports Liquid and solid carbohydrate sources must be available before, during and after all exercise.Exercise (Check and/or complete all that apply): FORMCHECKBOX  No exercise if most recent blood glucose is less than 70 or  FORMTEXT       FORMCHECKBOX  Eat  FORMTEXT      grams of carbohydrates before vigorous exercise FORMCHECKBOX  No exercise when blood glucose is greater than  FORMTEXT      or ketones are present FORMTEXT       FORMCHECKBOX  Following treatment for hypoglycemia, no P.E. participation until blood sugar is at least above 80 and a carbohydrate and protein snack has been given. Field Trips: Physician s Signature:Date: FORMTEXT      Juice, snacks, and/or Glucagon MUST be available to student on all field trips or bus trips in case student requires treatment of hypoglycemia. The driver/chaperone should know of any student with diabetes in their care, in the event of an emergency. Physician Form DIABETES MEDICAL MANAGEMENT PLAN This form must be renewed each school year or with any change in treatment plan Students Name:  FORMTEXT      Date of Birth: FORMTEXT       Blood Glucose Monitoring Target blood glucose range FORMTEXT      to FORMTEXT      Routine times to check blood glucose at school are: FORMCHECKBOX  before lunch FORMCHECKBOX  before exercise FORMCHECKBOX  after exercise FORMCHECKBOX  when student exhibits symptoms of hyperglycemia or hypoglycemia FORMCHECKBOX  other: FORMTEXT       FORMTEXT       FORMTEXT      Student can perform own blood glucose checks FORMCHECKBOX  School personnel must perform blood checks  FORMCHECKBOX  with supervision  FORMCHECKBOX  without supervision FORMCHECKBOX  Exceptions: FORMTEXT       Insulin AdministrLMdp{| ƻ砘wwwlaYNBhhW5CJaJhhWCJaJhWCJaJhL]hWCJaJhL]hWCJaJ"hohW56CJOJQJaJhW56CJOJQJaJhWCJ aJ h4;6CJOJQJh4;hW6CJOJQJaJh"J=6CJOJQJhG6CJOJQJh 6CJOJQJh-6CJOJQJhW6CJOJQJjh?]CUmHnHup  , T $=&#$/Ifgd]_gdW$a$gdW@&gd  $@&a$gd !    , . B D F P R T V QR$&(<>@JLɚ開yqfqXqjhWUmHnHujIhWUjhWU h0hWhhWCJaJhL]hWCJ aJ hWhWCJaJ%jhW5CJUaJmHnHu&jxhYhW5CJUaJhhW5CJaJ&jhYhW5CJUaJhW5CJaJjhW5CJUaJ!T V X B:1)$a$gdW $@&a$gd !$a$gdWkd$$Ifl\pA#z* 6=064 lap(yt]_ mQR&N $$Ifa$gd]_ $$Ifa$gd]_ $@&a$gd !$a$gdW & FgdWgdW 89:;<ssssj $Ifgd]_ $$Ifa$gd2[$a$gdWxkd$$Ifl0 * <0*64 lalyt]_ :;<FG  *,.8:<&(<>@JLN <>@BVܼܼܼܼynh2[hWCJaJh2[hW5CJaJjvhWUjhWUh2[hWCJaJh2[hWCJaJjhWU hB[ShWjhWUmHnHujhWUjhWUhL]hWCJ aJ hW hWhW hW>*)<>WKKKKK $$Ifa$gd2[kd$$Iflr@, !*@  th+644 lap2yt2[WKKKK? $$Ifa$gd2[ $$Ifa$gd2[kdj$$Iflr@, !*@  th+644 lap2yt2[ "$&NWKKKKB $Ifgd]_ $$Ifa$gd2[kdI$$Iflr@, !*@ th+644 lap2yt2[NPWKKKKK $$Ifa$gd2[kd$$Iflr@, !*@  th+644 lap2yt2[WKKKKK $$Ifa$gd2[kd$$Iflr@, !*@  th+644 lap2yt2[ <>@hWKKKB $Ifgd]_ $$Ifa$gd2[kd $$Iflr@, !*@ th+644 lap2yt2[VXZdfh$&(tv챦̝}qiaVJh hW6CJaJhDkhWCJ aJ h"J=CJ aJ h CJ aJ h& hW6CJaJhW6CJaJh 6CJaJjh?]CUmHnHuhW5CJaJj hWUhWh2[hWCJaJh2[hW5CJaJh2[hWCJaJ hB[ShWjhWUmHnHujhWUjU hWUhjlnoccWWW $$Ifa$gd2[ $$Ifa$gd2[kd $$Ifl\` !* p@  th+644 lap(yt2[WKKKKK $$Ifa$gd2[kd $$Iflr@, !*@ th+644 lap2yt2[WKKKB $Ifgd]_ $$Ifa$gd2[kd5 $$Iflr@, !*@ th+644 lap2yt2["occWWW $$Ifa$gd2[ $$Ifa$gd2[kd\ $$Ifl\` !* p@  th+644 lap(yt2["$WIC;66gdW$a$gdW@&gd @&^`gd"J=kd$$Iflr@, !*@ th+644 lap2yt2[ Bb @BVXZdfhjŹn^nRNhWh2[hW5CJ aJ j8h2[hW5U#jh2[hW5UmHnHujh2[hW5Ujh2[hW5Uh2[hW5hDkhW5CJ aJ hDkhW5hL]hW5CJaJhL]hWCJaJ"hohW56CJOJQJaJh 56CJOJQJaJhW56CJOJQJaJ"@hjZkd$$Ifl\ (E!*   L  t&+)44 lap(yt2[ $Ifgd]_ $@&a$gd !   &(JL`bdnpt  $jhWUjhWUjhWUh2[hW5h2[hW5CJ aJ jahWUjhWUjhWUmHnHujyhWUhWjhWU hDkhW5 "3kd$$IflֈTd(* e_{  t&+)44 lap<yt2[ $Ifgd]_"$&(Jrtckd$$Ifl\ F*&B   t&+)44 lap(yt2[ $Ifgd]_ <>T^?66666 $Ifgd]_kd$$Iflֈ s)*  G t&+44 lap<yt2[$&(24`bvxz.02<>VXlnpz|~ӽױӦӛӐӅjchWUjhWUj{hWUjhWUh2[hW5CJ aJ j=hWUjhWUhW hDkhWjhWUmHnHujhWUjUhWU4^kd$$Ifl֞ s)* H G t&+44 lapFyt2[ $Ifgd]_FHJT $Ifgd]_>' $Ifgd]_kd$$Ifl֞ s)* H G t&+44 lapFyt2[  &(*46NPdfhrtvxz   " $ & ( < > @ ja!hWUjhWUjShWUjhWUjhWUjhWUjhWUmHnHuj-hWUhWjhWU hDkhWh2[hW5CJ aJ 4>@BL $Ifgd]_' $Ifgd]_kd$$Ifl֞ s)* H G t&+44 lapFyt2[ " $ & 6kd? $$Iflֈs)*)HqG t&+44 lap<yt2[ $Ifgd]_@ J L R T h j l v x | ~ !!! !!!!2!4!6!@!B!D!F!Z!\!^!h!j!l!n!!!!!!!!Ƚȵߪߟߔ߉j}'hWUj'hWUj&hWUj%hWUh2[hW5h2[hWCJaJh2[hW5CJ aJ j!hWUhW hDkhWjhWUjhWUmHnHu1& N P R z | ~ 6kdM"$$Iflֈs)*)HqG t&+44 lap<yt2[ $Ifgd]_~ $Ifgd]_ kd#$$Ifloִ (m)*n M t&+    44 lapPyt2[ ! !6`kd&$$Ifl0*)% t&+44 lapyt2[`kd#%$$Ifl0*~ t&+44 lapyt2[ $Ifgd]_ !!D!l!!!!!!!fZZZ $$Ifa$gd2[kd'$$Ifl\*)U    t&+44 lap(yt2[ $Ifgd]_ !!!!!!!!!!!!!!""" """*"L"P"R"f"h"j"t"v"x"z"|""""""""D#H#J#V#X#l#n#p#z#|#~######ֽֽֽֽֽjC,hWUh2[hW5j*hWUj%*hWUj)hWUjhWUmHnHuj=)hWUjhWU hDkhWhWh2[hW5CJ aJ h2[hWCJaJ5!!!*"N""offff $Ifgd]_kd($$Ifl\*)U   t&+44 lap(yt2[""F#H#off $Ifgd]_kd +$$Ifl\(*)U   t&+44 lap(yt2[H#J#V#~####6`kd,$$Ifl08*& t&+44 lapyt2[ $Ifgd]_`kd+$$Ifl0*  t&+44 lapyt2[#################$$ $ $.$0$D$H$J$^$`$b$l$n$p$r$t$$$$$$$$$$$$$$$$$$%ӽױӛӐӅj0hWUjc0hWUj/hWUh2[hWCJaJh2[hW5CJ aJ j!.hWUj-hWUhW hDkhWjhWUmHnHujhWUj5-hWU3## $ $$$&$.$fZZZ $$Ifa$gd2[kd.$$Ifl\8=* X }  t&+44 lap(yt2[ $Ifgd]_.$0$F$$$%offff $Ifgd]_kdC/$$Ifl^\8=* _ }  t&+44 lap(yt2[%% %%%% %\%d%n%p%r%%%%%%%%%%%%%%%%%%%&&&&&$&&&(&*&,&@&B&D&N&P&X&`&d&f&z&|&~&&&׿쿴׿쿩׿׿쿞׿쿓׿쿈j5hWUj15hWUj4hWUj3hWUj3hWUhWh2[hW5h2[hW5CJ aJ hDkhWjhWUmHnHujhWUjK1hWU5% %\%^%`%b%offff $Ifgd]_kd1$$Ifl\*)! $  t&+44 lap(yt2[b%d%p%%%%offff $Ifgd]_kdy2$$Ifl\(*~  t&+44 lap(yt2[%%%%X&b&&& 'offfffff $Ifgd]_kd4$$Ifl\*X  t&+44 lap(yt2[&&&&&&&&&&&&&&&&&&&&&' ' '''"'&'('F'H'P'T''''q_"hohW56CJOJQJaJh"J=56CJOJQJaJh"J=CJ aJ hWCJ aJ h& hW6CJaJhW6CJaJjh?]CUmHnHuhW6CJOJQJj7hWUj6hWUjhWUmHnHuj6hWUjhWUhW hDkhW# '"'$''"gdWkdu7$$Ifl֞ *)#8/  t&+44 lapFyt2[$'H''>(`(((($&`#$/Ifgd2[$$&`#$/Ifa$gd2[ ^`gd"J= $@&a$gd !$@&^`a$gd"J='' (>(`(b(v(x(z(((((((((((((((()) )&)()*)N)P)R)n)׺ʨטʨב}rבbבj;h2[hW5UhL]hWCJaJhWCJaJh2[hW5CJaJ hDkhWj 9h2[hW5U#jh2[hW5UmHnHuj8h2[hW5Ujh2[hW5Uh2[hW5"hohW56CJOJQJaJhW56CJOJQJaJ!((((((hUUUB$$&`#$/Ifa$gd2[$$&`#$/Ifa$gd2[kd9$$Ifl\p*,X  t 6`h+644 lap(yt2[(((()P))f^^KKK$$&`#$/Ifa$gd2[$a$gdWkdG:$$IflG\p*,X  t 6`h+644 lap(yt2[n)p)r))))))))))))))B*D*F*Z*\*^*h*j*l*****V+X+l+n+p+Ƚ̯ԣȑȆ̯̑ȑxj`Uj_@hWUh2[hW56hl hW56CJ aJ hazhW5>*CJaJj=hWU h hWh2[hWCJaJh2[hW5CJaJjhWUmHnHuj;hWUhWjhWU hDkhWh2[hW5jh2[hW5Uj;h2[hW5U!))))))@--$$&`#$/Ifa$gd2[kdq<$$Iflrp $*  pT t 6`P+644 lap2yt2[$&`#$/Ifgd2[)))))D*-kd==$$Iflrp $*  pT t 6`P+644 lap2yt2[$&`#$/Ifgd2[$$&`#$/Ifa$gd2[D*l*****+++2+ph_SSSS $$Ifa$gd2[ $@&a$gd !$a$gdWkdq>$$IflFx$* t 6`P+6    44 lapyt2[$&`#$/Ifgd2[ 2+4+6+T+V+'kd ?$$Iflr)*$.' t0E+644 lap2yt2[ $Ifgd]_p+z+|++++++++++++++++++++++,,,,,$,&,*,,,@,B,D,N,P,R,T,X,n,,,,,,,߾߳ߨ㞐xxh2[hW6CJaJh2[hW6CJaJh2[hW56CJaJh2[hW56jBhWUj7BhWUjAhWUjKAhWUj@hWUhW h!?hWjhWUjhWUmHnHu/V+~++++++++,(,*,R,T,V,X,n,p,~,,,,,,,,, $$Ifa$gd2[FfKF $Ifgd]_,,,,,,--0-2-Z-\-^------------. ..FfW $Ifgd]_Ff1M $$Ifa$gd2[,,,,--- -- -"-,-.-2-4-H-J-L-V-X-^-`-t-v-x---------------------ԓyh2[hW6CJaJh2[hW56CJaJh2[hW56jRhWUjRhWUjRhWUjQhWUj'QhWU h!?hWjhWUmHnHujhWUjPhWUhW,.....0.>.@.J.L.N.Z.\........//./0/X/Z/\/^/Ff1gFfQ] $$Ifa$gd2[ $Ifgd]_-.,.J.\.^.r.t.v......................////// /*/,/0/2/F/H/J/T/V/X/\/ոձѦոձћոձѐոձхոձzոձjchWUjbhWUj/bhWUjahWUjCahWU h!?hWjhWUmHnHuj`hWUhWjhWUh2[hW56h2[hW6CJaJh2[hW6CJaJ/^/`/x/z///////////////0000 0H0J0 $@&a$gd !gdWFfm $$Ifa$gd2[ $Ifgd]_\/`/t///////0J0L0r0t000000000000000001 1 1111121ǻynycyjthWUjshWUjhWUmHnHujrhWUhWjhWU hXhWh2[hW5h2[hW56CJaJh& hW5CJ aJ hW5CJaJh2[hW56h2[hW6CJaJh2[hW6CJaJh2[hW56CJaJ%J0L0p0r0000?66666 $Ifgd]_kdgq$$Iflֈ 4|)*`   T h  p   tX+644 lap<yt2[00000116kds$$Iflֈ 4|)*` T hp  tX+644 lap<yt2[ $Ifgd]_214161@1B1F1H111111111111111111122202224262H2J2f2h2j2l2p2r22222˵Ϫ˔׆הx˔jqzhXhWUjyhXhWUjhXhWUh2[hWCJaJh2[hWCJaJj"whWUjvhWUhWh2[hW5 hXhWjhWUmHnHujhWUjuhWU+1D1F1H1~1116kdu$$Iflֈ 4|)*` T hp  tX+644 lap<yt2[ $Ifgd]_11111116kdw$$Iflֈ 4|)*` T hp  tX+644 lap<yt2[ $Ifgd]_11112r223?kdx$$Ifl\$ 4* pH  t0X+644 lap(yt2[ $Ifgd]_2222222222222:3<3>3R3T3V3`3d3x3z3|33333333333333ŸŨņvfjh2[hW5Uj/h2[hW5Uj~h2[hW5U#jh2[hW5UmHnHujC~h2[hW5Ujh2[hW5Uh2[hW5j]{hXhWU hXhWhWjhXhWUjzhXhWU$33333 3 3H????? $Ifgd]_kd{$$Ifl\$ 4* pH  t0X+644 lap(yt2[ 33<3"4$40''' $Ifgd]_kd|$$Iflr$ 4 |)* t p  t0X+644 lap2yt2[333334444 4&4V4X4l4n4p4z4~444444444444444455555*5ɹɲwlajhWUj4hWUjhWUjHhWUjhWUmHnHujҁhWUhWjhWU hB2hWjh2[hW5Uh2[hW5#jh2[hW5UmHnHujh2[hW5Ujh2[hW5U&$4&4V4<5>5~~~ $Ifgd]_wkd$$IflF$ |)* X p  tX+6    44 lapyt2[*5,5.585:5>5@555555555 6 6666062646>6@6D6F6H6J6^6`6b6l6p66666666666666666˵˪˟˔ˉ~jhWUjzhWUjhWUjhWUjMhWUjׅhWUjahWUhWh2[hW5 hB2hWjhWUmHnHujhWUj hWU1>5@55B6D6~~~ $Ifgd]_wkd$$IflF$ |)* X p  tX+6    44 lapyt2[D6F6H6z7|7~~~ $Ifgd]_wkdÆ$$IflF|)*p xp  tX+6    44 lapyt2[6667777 7*7.7B7D7F7P7T7h7j7l7v7x7|7~7777777777777777778 8 888.808ڹ첪ڟڔډ~sjhWUjmhWUjhWUjhWUj hWUh2[hW5 hB2hWjȊhWUjRhWUj܉hWUhWjhWUmHnHujhWUjfhWU-|7~7788~~~ $Ifgd]_wkd@$$IflF|)*  (p  tX+6    44 lapyt2[0828<8@8T8V8X8b8f8z8|8~88888888888889::::$:&:(::::::::uncjԑhWU h4!hWj^hWUh2[hW5CJaJh2[hW6h& hW5CJ aJ h4!hW5CJaJhW5CJaJh2[hW5 hB2hWjMhWUjՎhWUj]hWUhWjhWUmHnHujhWU&888889vj $$Ifa$gd2[ $@&a$gd !$a$gdWwkdŏ$$IflF|)*   ( p   tX+6    44 lapyt2[99:::::fGkd$$Ifl*+   t644 lap yt2[ $Ifgd]_Gkd$$Ifl*+    t644 lap yt2[::::::::;; ;; ;";,;.;0;;;;;;;;<<<2<4<6<@<B<D<p<r<t<<<<<<<<<<䍃h2[hW56jh2[hW56Uj֕hWUj^hWUjhWUjhWUmHnHujhWUj hWUhWh2[hW5CJaJ h4!hWjhWU,::;0;;;;||||| $Ifgd]_ykdL$$IflF)*   t6    44 lapyt2[;;<D<r<<<WNNNNN $Ifgd]_kd$$Iflrfo )* P'   t644 lap2yt2[<<=>>WNNN $Ifgd]_kdN$$Iflr.^o )* $ '   t644 lap2yt2[<<<>>>>>>>.>\>j>l>>>>>>>>>>ǻwshwZwSK@hShWCJaJhWCJaJ hKhWjhWUmHnHujhWUhWjhWU h,(hWh2[hW5hW5>*CJaJhhWCJaJh2[hW5CJaJh2[hWCJaJh2[hW5CJaJ h4!hWh2[hW6h2[hW56jh2[hW56U!j'h2[hW56U>>> > >>> $Ifgd]__kd$$Ifl0)*)   t644 lapyt2[>>>.>\>^>j>WRL<<<$&`#$/Ifgd2[@&gd !gdWkd&$$Iflr> ~!)*         t644 lap2yt2[j>>>H@_@`@p@VQII8$@&^`a$gd"J=$a$gdWgdWkd}$$Ifl\~ * :  t 6`644 lap(yt2[$&`#$/Ifgd2[>>x??? @&@'@G@H@`@a@o@p@t@y@@@@@@@@@ A AAAB׽um`mP`jIh2[hW5Ujh2[hW5Uh2[hW5hWhW5CJaJhL]hWCJaJ"hohW56CJOJQJaJhW56CJOJQJaJh"J=CJ aJ hWCJ aJ h& hW6CJaJjh?]CUmHnHuhW6CJaJhWCJaJhShWCJaJhO6hW5CJaJp@@@@ AB,BTBVBMkd9$$Ifl\J*(  th+644 lap(yt2[ $Ifgd]_ $$Ifa$gd2[gdW$a$gdWB B B,B.BBBDBFBPBRBTBVBXBBBBBBBBBBBCCCCCCC"CCCCгЬ{гІpгІdYjh-hWUh2[hW5CJaJjjhWUjhWU h-hWh&`hW5CJ aJ h,(hW5CJaJ hDkhW hKhWjhWUmHnHujhWUhWjhWUh2[hW5jh2[hW5U#jh2[hW5UmHnHu!VBXBBBBBCCC $Ifgd]_ $@&a$gd !$a$gdWCCC C"C?666 $Ifgd]_kd$$Iflֈ Uj~*  =    f   tP+44 lap<yt2["C$CCCC~~~ $Ifgd]_xkd$$IflEF(8$*    tP+    44 lapyt2[CCCC"DjDlD~~~~~ $Ifgd]_xkd$$IflaF(8$*    tP+    44 lapyt2[CCCCCCCCC"D$D@DBDDDhDlDnDpDDDDDEEEEE:EERETEVEjElEnEŷůߒ߫Ňׯ|qfj hWUh2[hWCJaJjhWUh2[hWCJaJjh-hWUj0hWUhWjhWUjhahWU hahWjhahWUh2[hW5 h-hWjh-hWUjHh-hWU#lDnDEEWNN $Ifgd]_kd$$Iflr (8$*    tP+44 lap2yt2[EETEEE $Ifgd]_akd$$Ifl40)*\*   tP+44 lapyt2[nExE|EEEEEEEEEEEEEEE,F.FJFLFNFFFFFFFFFFGG"G$G&G*GPGɾ|n||`|j`h-hWUjh-hWUjh-hWU h-hWjh2[hW5Ujh2[hW5Uh2[hWCJaJh2[hW5h2[hWCJaJ hahWjhWUjhWUhWjhWUjhWUmHnHu%EEEE*F,F|4||HkdH$$IflE*P+   tP+44 lap yt2[ $Ifgd]_ykdt$$Ifl4F)*" :%  tP+    44 lapyt2[,FFFFPGRGGGGfkd"$$Ifl+\t`)*   tP+44 lap(yt2[ $Ifgd]_PGRGTGpGrGtGGGGGGGGGGGGGH( ($(((())))|peYph2[hW6CJaJh2[hWCJaJh2[hW5CJaJh2[hW5CJaJUh2[hW5CJ aJ h2[hW5CJaJh2[hWCJaJh2[hWCJaJ#jh2[hW5UmHnHujLh2[hW5Uj֧h2[hW5Ujh2[hW5Uh2[hW5GGGGGGWNNNN $Ifgd]_kdĨ$$Ifl;rt`)*    tP+44 lap2yt2[GG ("(ocZ $Ifgd]_ $$Ifa$gd2[kd$$IflE\t)*        tP+44 lap(yt2[ation at SchoolInsulin administration at school by student as follows: (a. & b. not recommended independently below age twelve years)a. Determine insulin dose FORMCHECKBOX  Self perform-adult observe  FORMCHECKBOX  Nurse or parent-supervised FORMCHECKBOX  Dependent admin.b. Measure insulin FORMCHECKBOX  Self perform-adult observe FORMCHECKBOX  Nurse or parent-supervised FORMCHECKBOX  Dependent admin.c. Inject insulin (vial/pen) FORMCHECKBOX  Self perform-adult observe FORMCHECKBOX  Nurse or parent-supervised FORMCHECKBOX  Dependent admin.d. Insulin pump  FORMCHECKBOX  Self perform-adult observe FORMCHECKBOX  Nurse or parent-supervised FORMCHECKBOX  Dependent admin. Independent Management:  FORMCHECKBOX  Independent in Insulin administration (insulin should be kept in the health office or in the student s insulin pump.)Medication During School Hours Food/bolus doses (Check all that apply): FORMCHECKBOX  Standard lunchtime dose: FORMTEXT       FORMCHECKBOX  Lunch insulin to carbohydrate ratio: FORMTEXT      units FORMCHECKBOX  Humalog  FORMCHECKBOX  Novolog for 30 grams of carbohydrates FORMTEXT      units FORMCHECKBOX  Humalog  FORMCHECKBOX  Novolog for 45 grams of carbohydrates FORMTEXT      units FORMCHECKBOX  Humalog  FORMCHECKBOX  Novolog for 60 grams of carbohydrates FORMTEXT      units FORMCHECKBOX  Humalog  FORMCHECKBOX  Novolog for FORMTEXT      grams of carbohydrates FORMCHECKBOX  Correction Scale / Calculation:  Written sliding scale as follows:Blood Glucose from FORMTEXT      to FORMTEXT      = FORMTEXT      unitsBlood Glucose from FORMTEXT      to FORMTEXT      = FORMTEXT      unitsBlood Glucose from FORMTEXT      to FORMTEXT      = FORMTEXT      unitsBlood Glucose from FORMTEXT      to FORMTEXT      = FORMTEXT      unitsBlood Glucose from FORMTEXT      to FORMTEXT      = FORMTEXT      unitsBlood Glucose from FORMTEXT      to FORMTEXT      = FORMTEXT      units FORMCHECKBOX  Snack Bolus: FORMTEXT      units  FORMCHECKBOX  Humalog or  FORMCHECKBOX  Novolog for every FORMTEXT      grams of carbohydrates FORMCHECKBOX  Insulin Therapy for Disaster: Check blood glucose every 4 hours and give insulin using  FORMCHECKBOX  above scale or  FORMCHECKBOX  give Insulin following these instructions: FORMTEXT        FORMCHECKBOX  Insulin at school for this student is for disaster only. (Insulin doses should be given at least 2 hours apart to prevent overlapping insulin and hypoglycemia.) Physician s Signature:Date: FORMTEXT        Physician Form DIABETES MEDICAL MANAGEMENT PLAN This form must be renewed each school year or with any change in treatment plan Student s Name:  FORMTEXT      Date of Birth: FORMTEXT       A. Treatment of LOW blood sugar:  FORMCHECKBOX  less than 70  FORMCHECKBOX  less than 80  FORMCHECKBOX  Other  FORMTEXT       If hypoglycemic (low blood sugar) symptoms are present student must be supervised AT ALL TIMES! Following treatment for hypoglycemia, no P.E. participation until the blood sugar is at least above the blood sugar indicated above and a carbohydrate and protein Step 1: give student one of the following carbohydrate selections: 4 ounces (1/2 cup) any type of fruit juice 1 cup of milk 4 ounces (1/2 cup) regular soda  NOT DIET SODA! 2 - 3 glucose tablets 15 grams of Insta-Glucose"! 1 small tube of Cake Mate"! gel Step 2: Wait approximately  FORMCHECKBOX  10 OR  FORMCHECKBOX  15 minutes to allow blood glucose (BG) to rise  Do not give food yet.  FORMCHECKBOX  10 OR  FORMCHECKBOX  15 minutes to allow BG to rise, if lunchtime, may eat while waiting (should be supervised) Step 3: Recheck blood sugar: If BG (blood glucose) level is below the low blood sugar value checked above: Repeat Steps 1 and 2 again. If blood sugar does not rise above hypoglycemia level after 3 attempts then notify parents and the school nurse. If BG level is equal to or above the low blood sugar value checked above: Send the student to lunch, but if the lunch or snack is more than one hour away, 10 to 15 minutes after the Step 1 carbohydrate selection above:  FORMCHECKBOX  Follow with carbohydrate-and-protein-combination snack (e.g., cheese and crackers, peanut butter and crackers, of a meat or cheese sandwich)  FORMCHECKBOX  If Carb-counting, follow with a protein snack  FORMCHECKBOX  If Carb-counting, and going to PE before lunch, may have a carbohydrate and protein snack The student may return to scheduled class assignment, but may have difficulty concentrating for up to 1 hour following the hypoglycemic event. Glucagon (intramuscular injection): Glucagon dosage:  FORMCHECKBOX  1 mg If student loses consciousness or is having a seizure DO NOT put anything in the child s mouth Step 1: Administer Glucagon intramuscularly by school nurse, or trained personnel immediately Step 2: Call 911 immediately Step 3: Turn student to side (left side if possible) to avoid risk of aspiration Step 4: Notify the student s parent/guardian as soon as possible B. Treatment of HIGH blood sugar ( greater than 250 mg/dL):  FORMCHECKBOX  Student should drink 8 oz of water or DIET soda every hour and carry water bottle as needed  FORMCHECKBOX  Student should be excused to use restroom as often as needed  FORMCHECKBOX  Check urine ketones if blood sugar is greater than  FORMTEXT       Mg/dL. If moderate to large ketones, DO NOT allow student to exercise and contact parent or health care provider  FORMCHECKBOX  If student has nausea, vomiting, stomach ache, or is lethargic, call school nurse and parents as soon as possible. Monitor student and if needed call 911.  FORMCHECKBOX  Send student back to class if none of above physical symptoms are present.  Physician s Signature:Date: FORMTEXT      Physician s Name: FORMTEXT      Telephone: ( FORMTEXT      )  FORMTEXT       Physician s Address: FORMTEXT      Fax:( FORMTEXT      )  FORMTEXT       Advanced Practice Nurse Name: FORMTEXT      Telephone:( FORMTEXT      )  FORMTEXT            PAGE  San Bernardino County School District Form, Adapted from the National Diabetes Education Program Revised 4.10.14 Page  PAGE 2 of  NUMPAGES 5 "($())))) )")NHkd$$Ifl*P+    tP+44 lap yt2[ $Ifgd]_`kdl$$Ifle0)*\*     tP+44 lapyt2[))&)()^)`)b)~))))))))* *<*>*@*f*h*********+++N+P+l+ϮϜϊςp^#j|h2[hWCJUaJ#jh2[hWCJUaJh2[hW5#jdh2[hWCJUaJ#jh2[hWCJUaJ#jxh2[hWCJUaJjh2[hWCJUaJh2[hWCJaJh2[hW5CJaJh2[hWCJaJh2[hWCJOJQJaJ#")$)&)()kdL$$IflB֞  !!*     tP+44 lapFyt2[ $Ifgd]_()^)`)))**f* $Ifgd]_f*h***' $Ifgd]_kdڭ$$Ifl֞  !!*     tP+44 lapFyt2[***L+N++ $Ifgd]_l+n+p+++++++++4,6,R,T,V,,,,,,,,--- -"-$-`-b-~------ӼӪӘӆӼtb#jh2[hWCJUaJ#j"h2[hWCJUaJ#jh2[hWCJUaJ#j h2[hWCJUaJ#jh2[hWCJUaJh2[hWCJOJQJaJh2[hW5h2[hWCJaJjh2[hWCJUaJ#jh2[hWCJUaJ$++++' $Ifgd]_kdh$$Ifl֞  !!*     tP+44 lapFyt2[+2,4,,,, $Ifgd]_,,--' $Ifgd]_kd$$Iflu֞  !!*     tP+44 lapFyt2[-^-`---. $Ifgd]_---......N.T.V.r.t.v.d/f/h/////00000$0&0(0,0˿˳ˠӎӳˀt˿cOc&j h2[hW5CJUaJ jh2[hW5CJUaJh2[hW5CJaJh2[hW5>*CJ aJ #jηh2[hWCJUaJ hHhWh2[hW6CJaJh2[hW5CJaJh2[hW5CJaJh2[hW5h2[hWCJaJjh2[hWCJUaJ#jh2[hWCJUaJ.. . .' $Ifgd]_kd$$Ifl֞  !!*     tP+44 lapFyt2[ .....fkd$$Ifl`\a*   tP+44 lap(yt2[ $Ifgd]_..T.f/h///fZ $$Ifa$gd2[HkdD$$Iflh*P+   tP+44 lap yt2[ $Ifgd]_Hkdj$$Ifl`*P+   tP+44 lap yt2[///0006`kd2$$Iflw0)*\*   tP+44 lapyt2[ $Ifgd]_`kd$$Iflw0)*\*   tP+44 lapyt2[00^0000 $Ifgd]_Hkd$$IflG*P+   tP+44 lap yt2[,0\0^0`0t0v0x0000000000001111 11 1"1,1.101<1>1Z1ڰqڰbjh2[hWCJUaJ&jxh2[hW5CJUaJh2[hWCJaJ&j:h2[hW5CJUaJh2[hW5CJaJ+jh2[hW5CJUaJmHnHu&jh2[hW5CJUaJ jh2[hW5CJUaJh2[hW5CJaJh2[hW50000ofHkdֻ$$IflG*P+   tP+44 lap yt2[ $Ifgd]_kd$$Ifl\ |)* t   tP+44 lap(yt2[01111101<11fZNN $$Ifa$gd2[ $$Ifa$gd2[Hkd$$IflG*P+   tP+44 lap yt2[Hkd$$Ifl*P+   tP+44 lap yt2[ $Ifgd]_Z1\1^1x1z111111111112 2 2222&2(2D2F2H2b2d2222ӹӭӜr`N#jh2[hWCJUaJ#jLh2[hWCJUaJ+jh2[hW5CJUaJmHnHu&jԿh2[hW5CJUaJ jh2[hW5CJUaJh2[hW5CJaJh2[hW5#jfh2[hWCJUaJh2[hWCJaJjh2[hWCJUaJ#jh2[hWCJUaJ111116* $$Ifa$gd2[kdܾ$$Iflֈ\Ch)* j   tP+44 lap<yt2[ $Ifgd]_12&2222 $Ifgd]_ $$Ifa$gd2[22222222222233333.30323L3N3j3l3n33333333333ڵɟ~lX&jh2[hW5CJUaJ#jh2[hWCJUaJ#jh2[hWCJUaJjh2[hWCJUaJ+jh2[hW5CJUaJmHnHu&j0h2[hW5CJUaJ jh2[hW5CJUaJh2[hW5CJaJ h IhWh2[hW5h2[hWCJaJ"22233?3'' $$Ifa$gd2[ $$Ifa$gd2[kd8$$Iflֈ\Ch)* j   tP+44 lap<yt2[333336kd$$Iflֈ\Ch)* j   tP+44 lap<yt2[ $Ifgd]_3333t44444 $If^gd2[ $Ifgd]_ $$Ifa$gd2[ $$Ifa$gd2[3333334446484T4V4X4t4v4444444444444444zncnQ#j@h2[hWCJUaJh2[hWCJaJh2[hW5CJaJ&jh2[hW5CJUaJ#jzh2[hWCJUaJ#jh2[hWCJUaJjh2[hWCJUaJh2[hWCJaJh2[hW5CJaJ jh2[hW5CJUaJ+jh2[hW5CJUaJmHnHu44kdh$$Iflִ\C`2!)* b  ?  tP+    44 lapPyt2[44444X5Z5~xkd$$IflCF)*j '  tP+    44 lapyt2[ $Ifgd]_4>5V5X5Z5\5`5b5d55555555555666 66 6"6,6.6064666J6L6N6X6Z6\6h6j666֥{g&jh2[hW5CJUaJ&jh2[hW5CJUaJ+jh2[hW5CJUaJmHnHu&jh2[hW5CJUaJ jh2[hW5CJUaJh2[hW5CJaJh2[hW5CJaJh2[hW56h2[hWCJaJh2[hW5(Z5\5^5`5b56`kd@$$IflG0*j (  tP+44 lapyt2[ $Ifgd]_`kd$$Ifl0)*\*   tP+44 lapyt2[b5d55555556YM $$Ifa$gd2[kd$$Ifl\)*j    tP+44 lap(yt2[ $Ifgd]_ h$If^hgd2[660646\6h6 $Ifgd]_ $$Ifa$gd2[h6j6kd$$Iflִj( `2* n  tP+    44 lapPyt2[j6l6666667 7 $$Ifa$gd2[ $Ifgd]_ h$If^hgd2[666666666666666666777777 7"7J7L7`7b7d7n7p7r7v7x7z77θθθyeθ&jRh2[hW5CJUaJh2[hW5&jfh2[hW5CJUaJ&jh2[hW5CJUaJhWh2[hWCJaJ+jh2[hW5CJUaJmHnHu jh2[hW5CJUaJ&jvh2[hW5CJUaJh2[hW5CJaJ% 7"7kd$$Iflִj( `2* n  tP+    44 lapPyt2["7$7J7r7x77777 $$Ifa$gd2[ $Ifgd]_ h$If^hgd2[777777777777777788888&8(8*8.80828F8H8J8T8V8X8\8^8r8۹۹۹۹~۹z۹f۹۹&jh2[hW5CJUaJhW&j.h2[hW5CJUaJh2[hW5&jBh2[hW5CJUaJh2[hWCJaJh2[hW5CJaJ+jh2[hW5CJUaJmHnHu jh2[hW5CJUaJ&jh2[hW5CJUaJ#77kd$$Iflִj( `2* n  tP+    44 lapPyt2[778*808X8\888 $$Ifa$gd2[ $Ifgd]_ h$If^hgd2[r8t8v88888888888888888899 99999*9,9.989:9<9H9J9r9t99۹۹۹۹z۹۹f۹۹&jh2[hW5CJUaJ&jh2[hW5CJUaJhW&j h2[hW5CJUaJh2[hW5h2[hWCJaJh2[hW5CJaJ+jh2[hW5CJUaJmHnHu jh2[hW5CJUaJ&jh2[hW5CJUaJ%88kd$$Iflִj( `2* n  tP+    44 lapPyt2[8888899<9H9 $$Ifa$gd2[ $Ifgd]_ h$If^hgd2[H9J9kdr$$Iflִj( `2* n  tP+    44 lapPyt2[J9L9r999999: $$Ifa$gd2[ $Ifgd]_ h$If^hgd2[99999999999999999999999::::: :&:۹۹۹۹۹zoczTjh2[hWCJUaJh2[hW5CJaJh2[hWCJaJh2[hW5&jh2[hW5CJUaJ&j^h2[hW5CJUaJhWh2[hWCJaJh2[hW5CJaJ+jh2[hW5CJUaJmHnHu jh2[hW5CJUaJ&jh2[hW5CJUaJ::kdN$$Iflִj( `2* n  tP+    44 lapPyt2[::::J:r:;,;Z;}} $$Ifa$gd2[`kd$$Ifl=0*j (  tP+44 lapyt2[ $Ifgd]_ h$If^hgd2[&:(:*:0:H:J:L:`:b:d:n:p:r:::::::::::;;;Ӻr`OCh2[hW5CJaJ jh2[hW5CJUaJ#jh2[hWCJUaJ#j:h2[hWCJUaJ+jh2[hW5CJUaJmHnHu&jh2[hW5CJUaJh2[hW5CJaJ jh2[hW5CJUaJh2[hW5h2[hWCJaJjh2[hWCJUaJ#jLh2[hWCJUaJ;;;(;*;,;Z;\;^;`;b;d;f;h;j;;;;;;@<B<^<`<b<<<<<۹n\J#jh2[hWCJUaJ#j$h2[hWCJUaJ#jh2[hWCJUaJjh2[hWCJUaJh2[hW5CJaJh2[hWCJaJh2[hW5h2[hWCJaJh2[hW5CJaJ+jh2[hW5CJUaJmHnHu jh2[hW5CJUaJ&j&h2[hW5CJUaJZ;\;^;`;WJA $Ifgd]_ h$If^hgd2[kd$$Ifl=r *+ x  tP+44 lap2yt2[`;b;d;f;h;<<6`kd$$$IflG0)*\*   tP+44 lapyt2[ $Ifgd]_`kd$$Ifl=0*j (  tP+44 lapyt2[<<<<<=====(=*=,=.=0=:=<=>=@=\=^=`=d==>>>>>>>>>џule]YhWjhWU h,(hWhW5CJaJh2[hW6CJaJ#jh2[hWCJUaJh2[hW5CJaJh2[hWCJaJ(jh2[hWCJUaJmHnHu#jh2[hWCJUaJh2[hW5h2[hW5CJaJh2[hWCJaJjh2[hWCJUaJ <<<=,=.= $Ifgd]_`kd$$Ifl0)*\*   tP+44 lapyt2[.=0=2=4=:=<=offff $Ifgd]_kd$$Ifl\h)* K   tP+44 lap(yt2[<=>==>>offf $Ifgd]_kd$$Ifl>\h)* K   tP+44 lap(yt2[>>>>>>?$s&`#$/Ifgd2[gdW`kdB$$IflC0)*\*     tP+44 lapyt2[>?? ???????"?T?Z?\??????@B@^@`@½vgXFgFg;hL]hWCJaJ"hohW56CJOJQJaJh"J=56CJOJQJaJhW56CJOJQJaJh`o56CJOJQJaJhWCJ aJ h"J=6CJOJQJhW6CJOJQJ hG5)jh?]C6CJOJQJUmHnHu hW5hW5CJaJh2[hW5CJaJ hKhWjhWUmHnHujhWUjhWU???@??`@b@faTKFagd`o $@&a$gd ! $@&`a$gd"J=gdWkdR$$Ifl\~ * :*  t 6`s644 lap(yt2[`@b@@@@@@@@@@@@@@@@@@@:A>ԲAAAAA󳷳]鷳᳢WW2W5>*䴳W5>*䴳22< hDkhW hKhWjhWUmHnHujhWUhWjhWU#jh2[hW5UmHnHujh2[hW5Ujh2[hW5Uh2[hW5hW5CJaJ b@@@@@@@E@gd2[kd$$Ifl\0*(  t 6`*644 lap(yt2[$&`#$/Ifgd2[$$&`#$/Ifa$gd2[@@A$B&BB.D0DDE2EEEFFFHFakd$IfK$L$l0$I)$+ t644 lapyt2[ $Ifgd]_K$ $Ifgd]_AAAAAAABBB B"B&BB,D.D0D2D>D\DbDDDzEEFFHFJFݸ̢ݖxm_SGGxmh|hW>*CJaJh|hW6CJaJh|hW5>*CJaJhThWCJaJh!RhWCJaJhWCJaJh|hWCJaJh|hW5CJaJ+jh2[hW5CJUaJmHnHu&j8h2[hW5CJUaJ jh2[hW5CJUaJh2[hW5CJaJjhWUjhWUhWJFVFFFFFFFFFFFGGGVGbG|GGGGGGGGH HHH.H0H2H>HHHHHH(IshdhWh!RhWCJaJ#jh|hWCJUaJ#jh|hWCJUaJhW>*CJaJ#jh|hWCJUaJh|hW6CJaJ#j(h|hWCJUaJjh|hWCJUaJhWCJaJh|hWCJaJh|hW5>*CJaJ&HFFGHH(I*IIJJKLtMMxNROTOvPxPQQRR $If`gd]_ $If^gd]_$$If^a$gd]_ $Ifgd]_ $$Ifa$gd]_(I*I.IIIIIJJ|KKKKK,L0L\LhLjLLLLLLLLLL:MpMMMMMNŹŮйŹŦŹŦŦ}qhqhZhjhW6CJUaJhW6CJaJh|hW6CJaJ#jhoe,hWCJUaJjhWCJUaJhoe,hWCJaJhWCJaJhhWCJaJh|hW>*䴳|W䴳|W5C|W5>*䴳TW䴳󳢱ՒW䴳""*CJaJh!RhWCJaJhThWCJaJh|hWCJaJh97hWCJaJh97hW6CJaJ&jhoe,hW6CJUaJhoe,hWCJaJho;hW5CJaJhWCJaJhW6CJaJjhW6CJUaJ&jthoe,hW6CJUaJ QQQQQR|RRRRRRRRRRpSSSSTTTTT\T^TzTTTTTTյzq` jh|hW5CJUaJhW5CJaJhWCJaJh bhWCJaJh8hW5>*CJaJh!RhWCJOJQJaJhThWCJaJhW5>*CJaJhW5CJaJh|hW5CJaJh|hWCJaJh|hW5>*CJaJh|hW56CJaJhW RpSTTTTTrUVVVe(jh2[hWCJUaJmHnHu#jh2[hWCJUaJjh2[hWCJUaJh2[hWCJaJ&jDh2[hW5CJUaJ jh2[hW5CJUaJh2[hW5CJaJ&jh|hW5CJUaJh|hWCJaJh|hW5CJaJ jh|hW5CJUaJ&jXh|hW5CJUaJVWWW:W>WWWWWWWXXXXXXX.ʳYYYYYYZ@Zҭޟҋ}i[PhW5>*CJaJhnuhW5>*CJaJ&j8h|hW5CJUaJh|hW56CJaJhW5CJaJhW5>*CJaJh|hW5>*CJaJ&jh|hW5CJUaJ jh|hW5CJUaJh|hW5CJaJh|hWCJaJh2[hW5CJaJh2[hWCJaJWʳZuhhh_ $Ifgd]_ $If`gd]_$If^`gd]_ykd2$IfK$L$lFX) t6    44 lapyt2[>Z@ZBZpZrZ~ZZ $Ifgd]_gdWekd$$Ifl      0*0*0      64 lalyt]_@ZBZpZrZ~ZZZZZZZZZZZZZZZZZ [[[$[&[([2[4[6[8[:[N[P[R[ܸܿ䋝vodܿoYjUhWUjhWU hDkhW(jh2[hWCJUaJmHnHu#jih2[hWCJUaJjh2[hWCJUaJh2[hW5CJaJ hKhWjhWUmHnHuj4hWUhWjhWUh2[hWCJaJ hEhWhW5CJaJ"ZZZZ [f[mdddd $Ifgd]_kd$$Ifl;\$ *   t644 lap(yt2[R[\[^[f[h[[[[[[[[[[[[[[[[[[[[\\ \\\\ \\\^\r\t\v\\\\ꋀuc#jh2[hWCJUaJjrhWUjhWUhW(jh2[hWCJUaJmHnHu#jh2[hWCJUaJh2[hWCJaJjh2[hWCJUaJ hEhWh2[hW5CJaJ hDkhWjhWUjhWUmHnHu&f[h[[[[\mdddd $Ifgd]_kd$$Ifl\$ *   t644 lap(yt2[\ \\\\\\mdddd $Ifgd]_kd$$Ifl \$ *   t644 lap(yt2[\\\\\\\\\\\\\\\\\\\\\\\]]]] ]]]] ]"]$](]]] ^^~vnvh?]CCJaJh4;CJaJh4;5CJaJh4; h4;0Jjh4;0JUhJjhJUh5hWhWCJaJh2[hW5CJaJjhWUjhWUmHnHuj)hWUjhWU hDkhW hEhWhW&\\\\\]]] ] ]]]mhfffffffffgdWkd$$Ifl\\ * \   t644 lap(yt2[ ]$]&](]]^^__gd !$a$gd]_ &`#$gd]_^^^*^,^.^0^8^:^N^P^R^T^^^^__¾h5hJh4;hh4;CJaJh4;CJaJhCJaJmHnHujhM[h4;CJUaJhM[h4;CJaJ21h:p]_/ =!"#$% FF>OM]M5JFIFC      C  n" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?(((ڕzm0XBǰR47do[&ݑ,wq3F+:YAgyOKJ[7;%E'ON|E VeV4#&;t׎ [{'uU3Ğ>~k]@E}$a7b/tO$q,-Z=Wג9 ,ʧ3rz⽯kneVӤhN *rõy|Sx>ZbKRyc1ҴQg;0=x*곥9^[DOeoW_̰N*]ZI|-]}$P|tw6??i~}>X֯$H$fp@7ߴo/h>v=񹵺 " IEb#9>myIPT擄N],R O|~־>VմDLḼ;(I1 .j0]5wun1?2徶vz[rc7#LJ|!6Ϫ2xt;p,||q{qiwNdd\O *Rjڜw Y~!dPx /PN=!Ԥ0l7(3x>זS6q=*Ɵ46v˽4@9(< 6\vڷՓ<ʘ.q%w$׾>(V<r 붤Lcui4<{amեI$̌3C)#'g|J|/?x~[n,V7zNa2)c; >*躕τ_oo k1l%u<:ho;k߮׽݈F,}^Wk[Mּ_Fmo"okk m22FDĠUppF{o .,Uvmx,ꤱ@]E|>-57?d V!C#dO+V xv2[yi<Ĉ䉑K $tPZɧmm|޻z0R^ìV9]Տ4? CF_x?ڑG=٭,' B@ KNW$|,rIp-qLjgh:W+&?hz,zjkޠlŸB+WO_G]JkX/$Β2c۸K*TdzxNh'm;^ֲkˋrTkiʢ-i?hx G1g-ƧE'e#b_$6|aWŧt m'@}:X֯%8##p]'O>#xk9,|\tinl_gr܌ǧJ/=px6?:6n}&qO3ncb^"R*?N1m{ٶ5tniˎIJ;&T%WVZr~񇈼Mmi+WF]-o ͍5X'*ف TB{ya'|Ze;@#lu ,~Pm^>Ǟ*Լ?䶁6 aA;Ig!;> xquI7u fG[y\T?0vԭj1VJ7I])k]4g <>=sNmͨYʟtixo>k~h~ ԡҼ'Pi$EdX, 㷈K3Tt;Tjomcb.B#d[GCׇt=>kXd5 VSpa#?1⹝CT׼QS~+ht]RvƂ14Ir eAy~8)4n{j{"8U#):wWi'+Ywɴe;g;?xCѵmb n4:lu?+HtGESk (xxǟtx[Fa4]KcI$;mPk㍐24ԣk[jjY*׵/2JVt;nIEW!Q@Q@Q@IJ\d**keVT)UҒmz|%Nq4`W~/ѢlM}I1'K۴YV8Ի1;^9D/=#b0eMSZ3]X2U9l? Wy~!(xg>9\ד׏m$YVVܬ2zO r% *K <\Džgy' ~_JQsȖ(`f)k/ƞ!^ԵY4:erԬh\b۲&RQGP0sxPM:'8ZBMBSfVIw>)/Z/¿[KiI$7G]#?} v_|xV|;ymyrdNUIlsI&hU+g.ogǶ8\xMv)J)ptZRrQQOniIvjL_|O7K~ź,.ϋ~Ϩh> tЯ,c}ͅ}WҿmYֲn6څ[ td q rbԍJwo$j:>˸/*5̣+5$q[^`́r ?iO_+칯|#<7j66WZԚ*iEo)gxץGqt0p56ݼZF>q- rZ]$s|k_kM&?xvMOe #W C@ 4?^|C>+|1/R56X$ ^AkDn\ڿR-vRqY<=/Vԍ|K9zth M|S_)į7 Hn~*Gujb mbTe8޿7~9׿<+c{:W(KwXckQ?G>fn,Ҕԟ+?4V܍òPӔ:)8Kw~#12$i ^<孥I?LΞ8INN:_FM4Z+E!W,*(i;{՛^].M |LA{A+%Vy AY@H#xvk׈u+DQ9{(*4FWV^wiaUp4߲K_eI[WX먢`(3Q3O.|?aç_*}_¸Y?itv_웍 (\ʾ/@rJk_ɫvkɨOCxJd _xkW_jY$f9"PNzO_x;Z[Yf $ eOZ*ShfЖ&O[?:Nw_ X2:o3̰<12LǟZu\w{&iu}o%ژOas;[x|}Ҽ7LVR?%Ϫ)ݧudzֲܳꮳ<*%=_o?X+<u>&/K'??6ծO%鲹썳:X>"O-̭|W߱)>2i?ۃ[_\߀gl&|_ ~NϼkWO'ǿ0u?YNYcXḯ{iVUA<[ áĺչ)mY~ tz1SA<: lКoM[ŷAUxz*g?8˕̚MӍU׳G_-w {OKT|4I״kpThVTW2nnKXMeY#BJR|*qN)Ťgu۩? k彎۽6Ԏ5c8_ ?ss+[ AxaQc2*=41ںmG 㯏2~4mdaiVJæv@<0< 'ᧄB'K`Mă5LFSΫ3IE6d*sMcN,[Nr՛|v|3ž?~_u  ZWkx\ᦈ\w60폞yk&AD\]mPxKFGCo2rOcep뵁̾U/'FJWN)E&}˔h䴧EJnvz5| w?//4K_sȺ3Qż1Mz-6EVIJ*f+?eȴi/]wXa&_{8 $('$lؘ:k@tOWjb!g/l8yfkFOҧȤӻ$mlptE :GW}VV@ Fao)T漇O'A7p][}o۶ܽzg5?̨b+;F2oqN/'p$kCoN':Z|p}}mះ;6Nl󼨖=rqN3^Aknx$ v2fhw}jf)w GM:yWc8jJ_=_CU͍1ZDeF]; ? _K W|֟ |S vS>Q==~r;VOm-a%_w" TAQ ߄kשcR-/*mOm杺t~vIkwћN/=GV-M&YE* 4SWaz(9I)Com+CKKtBoVcOrI2XShE(vtK~m //*U5I7)-dEQEQECr8?ZFE9']Ey9CWiF7J]fͰ&Q>kMS"󭳅eZ(hUxaA=mo̗;-|?tۺ_}uay7'R'䝟K}SЕ-h3R^IKo($.Q9᷶m^F=M5arV# nUe%rn[>ζ"*}մٴЭ,̓lq#9ѻǝ<#ԫjJ/E> ~,|ShnU6=2O}1;gmxK>!xRȰ$ "*/(3EW|x7|mu- d\0"WR0GZSYeW*8S :y5_&h{L-%RKK[Nѿmlj ~4_7UΜ|{)#W*{8a|k]u-8xAK;'8"׎jSw9;@v29XM||^zI-yI}.L>ɧ ٴծk;6]_3R})ּ-!}J)56Ɋx/խﵽvJCRV+w*&\;ܰܰޒm]۳KԱ԰4[ڳ峾sT<ӄ¾EO|xѪh՛MœB&024 b|]_6Zv՝~$Tt)؞EeCT'm)owKo;ќT'gMIkg[(KֵOkfe/͏sȭ><5|=Ž/0g\A|?U-gʶѵEE&z4k[|ꗲ|IuKTz[I duO?jVv> ĺfwu-H˒bGm|& ៈ 4j'ji}6 c8 \9榦\J~뵬]]_O\Ҟq:05+%޾I%tϊV:Ɩ"='Sg!mNW=zй7wo\kω7:]ƾ'[f6s73! f to|3揥x'R=b 1`6G4E&W<py +d5TMn=Dߑr4Muiy^L`j??|xGě_MKŞ, WzȟBmQ\ Vkz5/o;Qe^Y J b71x|gy?5 Qg'쳋%23# V  8Snh$qvnyUTiԫE5 ŷVWfzOWMIͽƝ'K7zntM0ZP[ϵ75[3M*wp2y95E^!Okψ{;k64A<120,) Hc[U]|֧|1Uri-^]OpJ\LtzOZi棨G ֺr0u&+찭星 #~ǚIm}lAثIf3ovlLGOW:]]ӧ43F$e#YO'>,񜯍hj05۞w>]O\>咜gy'~gg5M~lռ;|$֮tچdn^ٚO۲4u|)ۤ}rNtqra'ֿ;mt'Zx{ĞKbwj VHw)*H!ze]O /I)-Sٵg+7q^nCHw~$Kx|E[_cͷG5z9C1i?>h^.4z.Fތ ة¿mVF(vi ]-' $T?S¿ ;Eos.Lx-#-!bx? ~ -<@<<ߴ[jz+A;ʧZ:^&Դ[~qqel2.;8??__&g׏'դ Q#* >e-?(۵@kVqUA>]dܯkݤ#lhbVNU&(0kE/6}|)gI`ϊ'>R9V^g)VDt%FЇ#x#q_íxN Z,^O4W$̫ g/wKwjbj]YyqZʤ)Ws㵜Z~iK%Χ=\~4ou$V]48~^ǩk,3jQG-2krS,LWHi߳jdlrxt[0GE}dyTυvcy#jz,K#1€2N X?i~Ѻd~ V c|ML?n2)_M%rx^7i4]va<~j1rM4Ӳ}U~ 敪I,|Z׶7xu䜺 6Z;/|+&e7aK$̀B*WMKgIhK䋉35RGÿXo סϋ.֝=son2aG`Z1a MZxhN)ɮedc+leJtV N.Q_j[6{e?mu+O[n{gefXT WWc=#LeQڔ1[\8yj}{~uoC,A[][]dTnUA*K-i8U@:O{ׇWZ{jk}5./JK}Kk_M6ؠk틋E1VgXlf?q߲/ÝGVJrn I#rrZHNIYN{טDo˧x=N+"6_FujP kǥs-ve}O),I5ef{cR1JvLj󬂽o:ԥ;\ÿ3}_s=_Qu+p/o'BSGWWME_VllYXBc޿5j;Uuӊ_ޒoQMr djvnU5Amg ̒7܌z^O^D6{U VºLv0qR~R{Q^`^bmS%GeZY}W.HMtQEW+o+h^2,u>L nqR vVΔJMKfMz4c_J*R5tS</oc#xkK%|9Of+I 08Rk3E 2+\f2*YR}ݺ1pT#ëB;+˲N˦ ,+?_ k,=G7X9;2eQF$?!7n|24kVh$;,>Ÿ饤%9^Gkd˳W+sBMYN]{thzY- |CiymUgJ9N]k5"52PtQqƿ5mO:_mῃZiu/ElEmKg{vG\2,!xXuf֬P~cQ}pƺ<=yR:ˮ=R'y3O_mOWmhKS&ih1Zֵ D~XpURP嘑IM;knO,/c3i~ >Xɳ۰/4H4Iŝaģu\ tHYW=KId-I*oWO^$dWUlm1_ӵxש~-طI^l0o87v6Ϫz*]\S+KZ2.Z3_"c| Ӿ&x?kh߯oʍ'ۀ2so?~&ci4@<+ܐ@xGSeWkc%寨boz*q3Ϋswڍ.wO6a><=N\D|C.~~~,u5~ 6fC&Eb3Ǐڇ:&^O!57ă'R&)' Vw%ޖfl"XQ~9P+jOkJvMݹUG>^qU2$JΜfԒ /o#}cp,W')~OԞ X.&MX.! bCgF5g c6#|A֑4Y$vw nۜrTdׇscf'w'{y'/vhLfk':rՔ#kmbnL>ǿR]__5IO?t\c&7}!mG?ExڶYB!b'3cWi7Goj,|S@a@*P/@vjݏS _LM'%?dQ綍tWw<<- x_E,aP!PFcܱ$Q'~%|+ DK I;_+`c_@mcelr?+޼~ԾԼsB|o )+v`"[ Y~wK0WŧJWQ&j׽[wp\Ty4Frrjkh~ҺM$>"֘Z./%زc2ѳ/?f8٫㻾V';&9\_YJ[lpAn= N[![YqH Xq+?i۫77rE ylv\s05/+ߓ{/廬=B/b<ۑ$Cb1zJԧ]U-ޮ]Owx# qz;ETREZ%i&n} KmQ_?mQ^?R-_+ЪFq)6>MZzj+E/o7#Pϊ8ۚdɹYkOiWg?:>kG&ռB3PqAWƹ?q7#W~Ξ&MKM|6]mcrPUyL\K)!Qi O?5BuK$sŭv~/"I`O)8Iahx2̱Zŷ~]mm뵼dG?x\糆²^Z@$@,#=\<'iDi6ާ߇MKS]K+4Zoj~io@Y3y91Z${X#2B"0Mk~:$VΟRhC[corI8SoUؼEiVI묃r2ïՙ;:]/+iZT E XOٛ^Ѵ'zrX]k4 :ϙi"Y7A+5Tњ['*؜M)={+tk|5×!ܓO<泩N.z7}n7h/bJ풿GM\k:M>K؛igLF9r W~Mze_^P"&rLQ֝G<7Z~uz\>{ڤMYȷ3ßi)<^F59Dj`w8eR6z!)4әwNJ>*ӷZ➋Ůx+b8$4E2߳gུц+3<?pAi};TO/l7/$0ȸHq:Ww4zƟaeأS4-$mnXc$Êc&ܖzzJ *|?d -clvzg+CrEdVsolOĿ^c9VB E\ R\JEg3FDlX$zέjtƎ_<%mo5ǖqXzwmJץ *BkKkiiuӯ<7h~ew33l&d[e, E^Zն ~KEn,:_d+-m yw3:jkUG)R&a! v ,MM[{qmsvs$@MeJZ]"2x1N?ifm=o*xEKګA_w ˮ}y>̟֯.߁|X}Ѷ}vZ 54y(7C4\i0![w$*ty(`\ \_Z,bM;͗|LKHTq]R/fR{|ӱ±TS.}:gI[Gno3Gkr.7>23\xI4QIxm$>ZnP`d}Myi%]^Oz77**`2FsX֚{?]Y.q>+^\O.@~IpČ0s}^Һ;oQNoUkkgRC謲f$|2 ti"|#%maP;qkZ^-\]ڦu7vQ% $̇ rI&xaw|?} m%}qf;Gq7[ ⷒRj^:5I8'YkޣSxAlKՏuxDǂuC v5&K7l/]gۢݿeznFq:i:nj4,O WSmRyz2o:ᾋ}E%F[0G^.\0p\jeMT[6? ȴWKQY{Emy;xDText162xDText163W$$If!vh#v#v#v#v:V l 6=065555/ / / / / / /  / 4p(yt]_xDText161$$Ifl!vh#v #v<:V l0*65 5</ / / / / 4alyt]_xDText157xDText154$$If!vh#v#v#v#v#v@ :V l th+6,55555@ / / / p2yt2[$$If!vh#v#v#v#v#v@ :V l th+6,55555@ / / / p2yt2[$$If!vh#v#v#v#v#v@ :V l th+6,55555@ p2yt2[xDText158xDText155$$If!vh#v#v#v#v#v@ :V l th+6,55555@ / / / p2yt2[$$If!vh#v#v#v#v#v@ :V l th+655555@ / / / p2yt2[$$If!vh#v#v#v#v#v@ :V l th+655555@ p2yt2[xDText156$$If!vh#v #vp#v#v@ :V l th+6,5 5p55@ / / p(yt2[$$If!vh#v#v#v#v#v@ :V l th+655555@ p2yt2[$$If!vh#v#v#v#v#v@ :V l th+655555@ p2yt2[xDText159$$If!vh#v #vp#v#v@ :V l th+6,5 5p55@ / / p(yt2[$$If!vh#v#v#v#v#v@ :V l th+655555@ p2yt2[tDText1tDText2$$If!vh#v#v#v#vL :V l t&+),5555L / /  / p(yt2[tDText3tDText4tDText5$$If!vh#v#v #ve#v_#v{#v :V l t&+),55 5e5_5{5 / / / / / p<yt2[$$If!vh#v#v&#vB #v :V l t&+),55&5B 5 / p(yt2[tDText6tDText7X$$If!vh#v#v #v#v#v #vG:V l t&+,55 555 5G/ / / / / / / / / / p<yt2[tDText8tDText9tDText8tDText9T$$If!vh#v#v #v#vH#v#v #vG:V l t&+,55 55H55 5G/ / / / / / / / pFyt2[tDText8tDText9tDText8tDText9T$$If!vh#v#v #v#vH#v#v #vG:V l t&+,55 55H55 5G/ / / / / / / / pFyt2[tDText8tDText9tDText8tDText9T$$If!vh#v#v #v#vH#v#v #vG:V l t&+,55 55H55 5G/ / / / / / / / pFyt2[vDText10vDText12 $$If!vh#v)#v#v#vH#vq#vG:V l t&+,5)555H5q5G/ / / / / / p<yt2[vDText11vDText13<$$If!vh#v)#v#v#vH#vq#vG:V l t&+,5)555H5q5G/ / / / / / / / p<yt2[$$If!vh#v#v#v#v#vn#v#v #vM:V lo t&+,55555n55 5M/ / / / / / / / / / /  pPyt2[z$$If!vh#v~#v:V l t&+,5~5/ pyt2[vDText14z$$If!vh#v)#v%:V l t&+,5)5%/ pyt2[vDText15vDText19vDText24$$If!vh#v)#vU #v #v :V l t&+,5)5U 5 5 / p(yt2[$$If!vh#v)#vU #v #v :V l t&+,5)5U 5 5 p(yt2[tDText8tDText9tDText8tDText9$$If!vh#v)#vU #v #v:V l t&+,5)5U 5 5/ / p(yt2[z$$If!vh#v #v :V l t&+,5 5 / pyt2[vDText25z$$If!vh#v#v&:V l t&+,55&/ pyt2[vDText29vDText32vDText36$$If!vh#v#v #vX #v} :V l t&+,55 5X 5} / p(yt2[$$If!vh#v#v #v_ #v} :V l^ t&+,55 5_ 5} / p(yt2[tDText8tDText9tDText8tDText9$$If!vh#v)#v! #v$ #v:V l t&+,5)5! 5$ 5/ / p(yt2[$$If!vh#v~#v #v#v :V l t&+,5~5 55 p(yt2[vDText38vDText43$$If!vh#vX#v#v#v :V l t&+,5X555 / / p(yt2[tDText8tDText9tDText8tDText9tDText8tDText9$$If!vh#v)#v##v#v8#v#v#v/ :V l t&+,5)5#558555/ / / / / pFyt2[vDText47vDText48$$If!vh#v#v,#v#vX :V l t 6`h+6,55,55X / / p(yt2[$$If!vh#v#v,#v#vX :V lG t 6`h+6,55,55X / / p(yt2[tDeCheck4tDeCheck5vDText49$$If!vh#v#v #v #vp#vT:V l t 6`P+655 5 5p5T/ p2yt2[$$If!vh#v#v #v #vp#vT:V l t 6`P+655 5 5p5Tp2yt2[vDText50$$If!vh#v#v#v:V l t 6`P+6555/ pyt2[P$$If!vh#v #v/#v#v#v&:V l t0E+655$55.5'/ / /  / / /  / / p2yt2[vDText51vDText52vDText53vDText54vDText55vDText56&$$If!vh#v#v#v:#v#v#v#v0#v#v #v #v B#v #v c#v :V lU t0E+6,, 5,552555555 5 5 F5 5 h5 / / / / / / / / / / / / / / / / /  / / /  / /  /  /  / p֌yt2[Nkd#C$$IflU8 !F#*,2Fh t0E+6888844 lap֌yt2[$$If!vh#v#v#v:#v#v#v#v0#v#v #v #v B#v #v c#v #v:V l t0E+65,552555555 5 5 F5 5 h5 5/ / / / / / / / / / / / / / / / / / /  /  / / / / / / / / / / / / p֖yt2[~kdI$$IflN !F#)*,2Fh t0E+6<<<<44 lap֖yt2[vDText57vDText59vDText61vDText63vDText65vDText67$$If!vh#v#v#v:#v#v#v#v0#v#v #v #v B#v #v c#v #v:V l t0E+65,552555555 5 5 F5 5 h5 5/ / / / / / / / / / / / / / / / / / / /  /  / / / / / / / / / / / / p֖yt2[zkduS$$IflN !F#)*,2Fh t0E+6<<<<44 lap֖yt2[$$If!vh#v#v#v:#v#v#v#v0#v#v #v #v B#v #v c#v #v:V l t0E+65,552555555 5 5 F5 5 h5 5/ / / / / / / / / / / /  / /  /  /  / p֖yt2[zkdZ$$IflN !F#)*,2Fh t0E+6<<<<44 lap֖yt2[vDText58vDText60vDText62vDText64vDText66vDText68$$If!vh#v#v#v:#v#v#v#v0#v#v #v #v B#v #v c#v #v:V l t0E+65,552555555 5 5 F5 5 h5 5/ / / / / / / / / / / / / / / / / / / /  /  / / / / / / / / / / / / p֖yt2[zkdc$$IflN !F#)*,2Fh t0E+6<<<<44 lap֖yt2[<$$If!vh#v#v#v:#v#v#v#v0#v#v #v #v B#v #v c#v #v:V l t0E+65,552555555 5 5 F5 5 h5 5/  / / / /  / / / /  / / / / / / /  /  / / / / / / / / / p֖yt2[zkdj$$IflN !F#)*,2Fh t0E+6<<<<44 lap֖yt2[5$$If!vh#v` #v#vT #vh#v#vp:V l tX+65` 55T 5h55p/  / / / / /  /  / p<yt2[vDText69vDText70$$If!vh#v` #v#vT #vh#v#vp:V l tX+65` 55T 5h55p/  / / / / /  p<yt2[vDText71vDText72$$If!vh#v` #v#vT #vh#v#vp:V l tX+65` 55T 5h55p/  / / / / /  p<yt2[vDText73vDText745$$If!vh#v` #v#vT #vh#v#vp:V l tX+65` 55T 5h55p/  / / / / / / /  p<yt2[*$$If!vh#v #v#vp#vH :V l t0X+65 55p5H /  / / / / / /  p(yt2[vDeCheck23vDeCheck24vDeCheck25vDeCheck27*$$If!vh#v #v#vp#vH :V l t0X+65 55p5H /  / / / / / /  p(yt2[B$$If!vh#v #v#v#vt #vp:V l t0X+65 555t 5p/  / / / / / /  p2yt2[vDText75vDText76vDText77vDText78vDText79vDText80$$If!vh#v #vX #vp:V l tX+6,5 5X 5p/  / / / /  pyt2[vDText81vDText82vDText83vDText84vDText85vDText86$$If!vh#v #vX #vp:V l tX+6,5 5X 5p/  / / / /  pyt2[vDText87vDText88vDText89$$If!vh#vp#vx#vp:V l tX+6,5p5x5p/  / / / /  pyt2[vDText90vDText91vDText92vDText93vDText94vDText95vDText96xDText105$$If!vh#v #v(#vp:V l tX+6,5 5(5p/  / / / /  pyt2[vDText97vDText98vDText99xDText100xDText101xDText102xDText103xDText104$$If!vh#v #v(#vp:V l tX+6,5 5(5p/  / / / /  /  pyt2[[$$If!vh#v+:V l t65+/  p yt2[a$$If!vh#v+:V l t6,5+/  p yt2[vDeCheck54xDText106$$If!vh#v/#v#v:V l t6,555/  / / /  pyt2[vDeCheck30xDText107$$If!vh#v#v#vp#v #v:V l t6,555P5' 5/  / / /  p2yt2[vDeCheck31xDText108xDText153$$If!vh#v#v0#v #v:V l t6,555$ 5' 5/  / /  p2yt2[vDeCheck55$$If!vh#v)#v:V l t6,5)5/  /  pyt2[$$If!vh#v #v@#v#v#v:V l t6,5 5 555/  /  /  p2yt2[xDText109$$If!vh#v #v:#v#v :V l t 6`6,5 5:55 / / p(yt2[xDText110xDText111$$If!vh#v(#v#v#v :V l th+6,5(555 / / p(yt2[xDText112xDText113 $$If!vh#v #v=#v#v#v#vf:V l tP+,5 5=5555f/  / / / /  /  p<yt2[$$If!vh#v#v #v:V lE tP+,55 5/  /  pyt2[$$If!vh#v#v #v:V la tP+,55 5/  /  pyt2[tDeCheck6tDeCheck8tDeCheck9$$If!vh#v #v#v#v #v:V l tP+,,,5 555 5/  /  p2yt2[tDeCheck7$$If!vh#v\*#v:V l4 tP++,5\*5/  / /  pyt2[vDeCheck22xDText114xDText115xDText116$$If!vh#v"#v:%#v:V l4 tP++,5"5:%5/  / / / /  pyt2[b$$If!vh#vP+:V lE tP+,5P+/  p yt2[vDeCheck13$$If!vh#v#v#v#v:V l+ tP+,5555/  / /  p(yt2[vDeCheck11vDeCheck12vDeCheck13xDText117$$If!vh#v#v#v#v #v:V l; tP+,5555 5/  /  p2yt2[$$If!vh#v#v#v #v:V lE tP+,555 5/  /  /  /  p(yt2[z$$If!vh#v\*#v:V le tP+,5\*5/  pyt2[b$$If!vh#vP+:V l tP+,5P+/  p yt2[*$$If!vh#v #v#v #v#v #v#v:V lB tP+,5 55 55 55/  /  / / /  pFyt2[vDeCheck17vDeCheck18vDeCheck20*$$If!vh#v #v#v #v#v #v#v:V l tP+,5 55 55 55/  /  / / /  pFyt2[vDeCheck19vDeCheck20vDeCheck20*$$If!vh#v #v#v #v#v #v#v:V l tP+,5 55 55 55/  /  / / /  pFyt2[vDeCheck16vDeCheck16vDeCheck20*$$If!vh#v #v#v #v#v #v#v:V lu tP+,5 55 55 55/  /  / / /  pFyt2[vDeCheck16vDeCheck16vDeCheck20*$$If!vh#v #v#v #v#v #v#v:V l tP+,5 55 55 55/  /  / / /  pFyt2[$$If!vh#v#v#v#v:V l` tP+,5555/  /  p(yt2[b$$If!vh#vP+:V l` tP+,5P+/  p yt2[vDeCheck15b$$If!vh#vP+:V lh tP+,5P+/  p yt2[$$If!vh#v\*#v:V lw tP+,5\*5/  /  pyt2[$$If!vh#v\*#v:V lw tP+,5\*5/  /  pyt2[b$$If!vh#vP+:V lG tP+,5P+/  p yt2[vDeCheck35xDText118$$If!vh#v #v#vt #v:V l tP+,5 55t 5/  / /  p(yt2[b$$If!vh#vP+:V lG tP+,5P+/  p yt2[vDeCheck36b$$If!vh#vP+:V l tP+,5P+/  p yt2[b$$If!vh#vP+:V lG tP+,5P+/  p yt2[xDText119vDeCheck37vDeCheck38$$If!vh#v#v#v#vj#v #v:V l tP+,5555j5 5/  / /  p<yt2[xDText120vDeCheck37vDeCheck38$$If!vh#v#v#v#vj#v #v:V l tP+,5555j5 5/  / /  p<yt2[xDText121vDeCheck47vDeCheck48$$If!vh#v#v#v#vj#v #v:V l tP+,5555j5 5/  / /  p<yt2[xDText122vDeCheck47vDeCheck48xDText1234$$If!vh#v#v#v#vb #v#v #v?#v:V l tP+,5555b 55 5?5/  / / /  pPyt2[$$If!vh#vj#v'#v:V lC tP+,5j5'5/  /  pyt2[vDeCheck51$$If!vh#v\*#v:V l tP+,5\*5/  /  pyt2[$$If!vh#vj#v(:V lG tP+,5j5(/  / / /  pyt2[$$If!vh#vj#v#v #v:V l tP+,5j55 5/  /  p(yt2[xDText124xDText130xDText136l$$If!vh#v#v#v#v#v#vn#v#v:V l tP+,555555n55/  / / /  / / / /  pPyt2[xDText125xDText131xDText137r$$If!vh#v#v#v#v#v#vn#v#v:V l tP+,,555555n55/  / / / /  / / /  pPyt2[xDText126xDText132xDText138r$$If!vh#v#v#v#v#v#vn#v#v:V l tP+,,555555n55/  / / / /  / / /  pPyt2[xDText127xDText133xDText139r$$If!vh#v#v#v#v#v#vn#v#v:V l tP+,,555555n55/  / / / /  / / /  pPyt2[xDText128xDText134xDText140r$$If!vh#v#v#v#v#v#vn#v#v:V l tP+,,555555n55/  / / / /  / / /  pPyt2[xDText129xDText135xDText141r$$If!vh#v#v#v#v#v#vn#v#v:V l tP+,,555555n55/  / / / /  / / /  pPyt2[$$If!vh#vj#v(:V l= tP+,5j5(/  /  pyt2[vDeCheck58xDText142vDeCheck37vDeCheck38xDText143$$If!vh#v+#v#vx#v#v:V l= tP+,5+55x55/  / / / /  p2yt2[$$If!vh#vj#v(:V l= tP+,5j5(/  /  pyt2[$$If!vh#v\*#v:V lG tP+,5\*5/  /  pyt2[vDeCheck65vDeCheck66vDeCheck67$$If!vh#v\*#v:V l tP+,5\*5/  /  pyt2[xDText144$$If!vh#v#vK #v#v:V l tP+,55K 55/  / / / /  p(yt2[$$If!vh#v#vK #v#v:V l> tP+,55K 55/  / / /  p(yt2[vDeCheck65$$If!vh#v\*#v:V lC tP+,5\*5/  /  /  pyt2[xDText152$$If!vh#v #v:#v*#v :V l t 6`s6,5 5:5*5 / / p(yt2[xDText145xDText146$$If!vh#v(#v#v#v :V l t 6`*6,5(555 / / p(yt2[vDeCheck32vDeCheck33vDeCheck34xDText147v$IfK$L$l!vh#v$#v+:V l t65$5+/ pyt2[vDeCheck56vDeCheck57vDeCheck56vDeCheck56tDeCheck1tDeCheck2tDeCheck2vDeCheck42$$Ifl!vh#v0*:V l0      650*4alyt]_vDeCheck60vDeCheck61vDeCheck62xDText160$IfK$L$l!vh#v#v#v:V l t6555/ pyt2[vDeCheck63vDeCheck64$$Ifl!vh#v0*:V l0      650*4alyt]_xDText149$$If!vh#v #v#v#v :V l; t6,5 555 / / p(yt2[xDText148tDText8tDText9$$If!vh#v #v#v#v :V l t6,5 555 / / p(yt2[xDText150tDText8tDText9$$If!vh#v #v#v#v :V l  t6,5 555 / / / p(yt2[xDText151tDText8tDText9$$If!vh#v #v\ #v#v :V l t6,5 5\ 55 / / p(yt2[^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ WNormalCJ_HaJmH sH tH DA`D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List jj W Table Grid7:V044 WHeader  !4 @4 WFooter  !.)@!. W Page NumberH@2H W Balloon TextCJOJQJ^JaJJoAJ WESD+567>*B* CJOJQJ\]aJphZY@RZ  ! Document Map-D M CJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] >  V$@ !#%&'n)p+,-\/2123*5608:<>CԷʳ)+-,012346789&:;<>`@AJF(IN QTV@ZR[\^_$&*179=AEKORVY\adfhkortwy|T <Nh""^>& ~ !!"H##.$%b%% '$'(())D*2+V+,.^/J001113 3$4>56789:;<>>j>p@VBC"CClDEE,FGG"(")()f**++,-. ../0001123344Z5b56h6j6 7"77788H9J9::Z;`;<.=<=>?@RZڰ\%'()+,-./0234568:;<>?@BCDFGHIJLMNPQSTUWXZ[]^_`bcegijlmnpqsuvxz{}~ 0<B-9?U a g l x ~      $ 0 6 ? K Q \ h n $'39Yeknz *0@LR^jpu$*KW]`lr +7=?KQS_e&,<HNbntw @LR ".47CIMY_bntw #&28;GM ".47CIk{ %&289EKLX^_kqIU[\hno{  ".45AGHTZ[gmnzeu-=p|l x ~ !B!R!e!u!!!!!""#"/"5"6"B"H"I"U"["""""" #"#2#C#O#U#)$9$Y$i$$$$$$% %0%d%t%%%%%% &)&9&X&h&&&|'''''''' ((('(5(E(r(~((((((((()))/)\)h)n)v)))))))))f*r*x*}**************++*+0+5+A+G+K+W+]+z+++++++++++++++,,,2,>,D,I,U,[,_,k,q,},,,,,,,,,,- ---=------. ..(....//////0(0=0M0_0o0w0002223g3w33355u666677994:D::::::f;v;:<J<<<<<<<= ===!='=B=N=T=\=h=n=q=}===========>FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFG$G$FFFFFFFFFFFFFFFFFFFFFFFFFFG$G$G$G$FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFG$FG$FG$FFG$FFFFFG$G$G$G$G$FFFG$G$G$G$FG$G$G$G$G$G$G$G$G$G$G$G$G$G$FG$FG$G$FG$G$FG$G$FG$G$FG$FFFFFFFFFFFFFFFFFFG$FG$G$FG$G$G$FG$FFFG$G$G$FG$G$G$G$G$G$G$G$G$G$G$FG$G$FFFFFFFFFF !!t ,R$>OM]M5F4@H 0(  ,(  J  A>?>. "SBCSS-Logo2013-4Line-2Color-GTPicture 1SBCSS-Logo2013-4Line-2Color-GTJJjR`TjR`TJ3"`?J  A>?>. "SBCSS-Logo2013-4Line-2Color-GTPicture 1SBCSS-Logo2013-4Line-2Color-GTJJjR`TjR`TJ3"`?J  A>?>. "SBCSS-Logo2013-4Line-2Color-GTPicture 1SBCSS-Logo2013-4Line-2Color-GTJJjR`TjR`TJ3"`?J  A>?>. "SBCSS-Logo2013-4Line-2Color-GTPicture 1SBCSS-Logo2013-4Line-2Color-GTJJjR`TjR`TJ3"`?J  A>?>. "SBCSS-Logo2013-4Line-2Color-GTPicture 1SBCSS-Logo2013-4Line-2Color-GTJJjR`TjR`TJ3"`?B S  ? />$.+@$*@#*@$+<@%fz+@Text162Text163Text161Text157Text154Text158Text155Text156Text159Text1Text2Text3Text4Text5Text6Text7Text8Text9Text10Text12Text11Text13Text14Text15Text19Text24Text25Text29Text32Text36Text38Text43Text47Text48Check4Check5Text49Text50Text51Text52Text53Text54Text55Text56Text57Text59Text61Text63Text65Text67Text58Text60Text62Text64Text66Text68Text69Text70Text71Text72Text73Text74Check23Check24Check25Check27Text75Text76Text77Text78Text79Text80Text81Text82Text83Text84Text85Text86Text87Text88Text89Text90Text91Text92Text93Text94Text95Text96Text105Text97Text98Text99Text100Text101Text102Text103Text104Check54Text106Check30Text107Check31Text108Text153Check55Text109Text110Text111Text112Text113Check6Check8Check9Check7Check22Text114Text115Text116Check13Check11Check12Text117Check17Check18Check19Check20Check35Text118Text119Text120Text121Check47Check48Text122Text123Check51Text124Text130Text136Text125Text131Text137Text126Text132Text138Text127Text133Text139Text128Text134Text140Text129Text135Text141Check58Text142Text143Check65Check66Check67Text144Text152Text145Text146Check32Check33Check34Text147Check56Check57Check1Check2Check42 OLE_LINK1 OLE_LINK2Check60Check61Check62Text160Check63Check64Text149Text148Text150Text1511.V m  % @ ] A_v,@T= A#8Ncx'<#8l':M`J]p #6I\of.qm C!f!!!"$"7"J""""D#*$Z$$$}'''s(() )])))g*~*****+6+L+{+++++,3,J,`,},,,.----.//0>000225679992:::;8<<<C==>  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~ C@h    7 R o Sq+ >Rf-OS 5J`u$9N 5J|&9L_r\o 5H[nv> !S!v!!!"6"I"\""" #V#:$j$$%''((()0)o)))y*****+1+H+^+++++,,E,\,r,,,->---.///)000023567999:::;<<<U==>88888A > >>#>>P>">2>2>>9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType " k2p299::========>> >>>>>>>2322=======>>n>~>>>3333333d !0F-AU 4 S   $ 8 ? S \ v @U^. "+i.<Q-@[ S"RuIpl[ l !B!!"#"a""C#h## $$)$$$I%d%%%&-'N'|''''((r((((()\)p)))+*S*f*z*}*********++2+5+I+K+_+z+++++++++,,,2,F,I,],_,s,,,,-----...///////0999::<<<<<B=V===========>> > >n>>>>>>>Md / 2   -12233////#/&/W/Y///==========>>w>~>>>wRjFa!J\*og&JZ$F IJ\p5RRh^`OJQJ^Jo(hHoh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHhhh^h`OJQJ^Jo(hHoh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhhh^h`OJQJ^Jo(hHoh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHwp5Rj Ia!*og&                                     4;3{8^(s@02  NvpZyGU2[|V $Vv~tx :?OdHi! E!x"+ #S"#$v#&0&i&]7';(I)*_9*bf*+1+-^-//g]0"y0 2|2\3e4&p45%5r6q6A7D8 9D9;e;K;5=.F="J=Z= @".@A?]CD?FOF\F:GbGlHIV,IrK3-LDLWLcL9NM1NWNYPz\QeQSXRcdSRUVK'W}`XlXXGZ@nZ [5\_7w`pa9by\bdke1g ghhhizuiajk@=kWkVuk4alwl?mR pEpMpOprhr!Gu&vpw[xxXySuy{{{J|M| }~kW q\MaCG(5:k3+zo_aJjX2`#/eWaV:dJ'EijzmR rDu&q_!WvU$s] !^i2KpRp(]_ejL9J2@N9)g %Zh@0NaRuwDFfZ1[aWl`o$f`" izgT-bt ig "sGL^I~W*G==@lb b b b bbbbbbbbbbbbbbbbby y!y"y#>@ @$@ "&(*,.02468:<>@BDF(Unknown G*Ax Times New Roman5Symbol3. *Cx ArialA. Arial NarrowINMonotype Corsiva5. .[`)TahomaCNComic Sans MS?= *Cx Courier New;WingdingsA$BCambria Math"1hu[&gu[&g? 4p? 4p!4==2QHP ?W! xx  Parent Form Charlene Dean Technology$      Oh+'0@x    (08 Parent FormCharlene DeanNormal Technology2Microsoft Office Word@@:!@:!? 4՜.+,0 hp|  ESDp=  Parent Form Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&')*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F0g@Data (1TableLnWordDocumentNSummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q