Order now and save! $920 after 8/15/12 - Suffield Academy
Order now and save! $920 after 8/15/12 - Suffield Academy Order now and save! $920 after 8/15/12 - Suffield Academy
[ suffield academy [ Suffield, Connecticut / 860.386.4400 2012/13 student forms ID# date of birth PERMISSION FOR MEDICAL OR SURGICAL TREATMENT Treatment Waiver: This form must be signed by the student’s parent or legal guardian so that appropriate diagnosis and treatment may be promptly administered and so that no unnecessary delays will occur in case of a medical or surgical emergency. In the event of an emergency, every attempt will be made to contact and fully inform the parents or legal guardian. I hereby authorize the physician (M.D.) of Suffield Academy, Suffield, Connecticut, to procure and administer any care, medical or surgical, and any hospital care deemed necessary to restore health to my son or daughter. My son or daughter has my permission to self-administer any medication, ordered by the school physician or consulting physician, with the approval of the school nurse. The Headmaster or his designee may give permission for surgical or medical treatment for my son or daughter in the event I/we cannot be contacted. I authorize the school nurse or authorized faculty member to administer medications prescribed by the school physician or consulting physician. I further authorize that medical information be released to faculty and advisors on a need to know basis. NAME OF STUDENT First Name Last Name middle Name Student’s Social Security Number List Any Known Allergies Parent or Guardian Name (please print and sign here if you intend to use a printed copy of this form) Date By checking this box and entering the student ID number above, you are signing this document electronically. PARENT or guardian CONTACT INFORMATION Name relationship to Student Street City State Country Zip Code Home Phone Cell Phone Business Phone Email IN CASE the PARENT or guardian listed above cannot be reached, please contact Name relationship to Student Street City State Country Zip Code Home Phone Cell Phone Business Phone Email MEDICAL INSURANCE INFORMATION Is a referral needed PCP Name Phone Fax Name of Insurance insurance Company’s Phone Number Address to mail claim form Name of Subscriber Subscriber’s Date of Birth Subscriber’s Place of Employment Insurance Identification Number Subscriber’s Social Security number [ PLEASE PROVIDE AN ENLARGED COPY OF THE FRONT AND BACK OF ALL INSURANCE CARDS FORM: TREATMENT / DUE: 07.15.12 [
[ suffield academy [ Suffield, Connecticut / 860.386.4400 2012/13 student forms ID# date of birth PHYSICAL EXAMINATION RECORD FOR RETURNING STUDENTS Please be thorough. Omission of known health problems can jeopardize a student’s health care and well-being. A physical examination must be filed each year before a student may participate in any part of the school program. Physical must be done within one year. NAME OF STUDENT First Name last Name Middle Name Blood pressure Pulse Asthma (preventative & emergency treatment) Height Weight inches pounds Allergies (please list) Immunizations since last physical: Current medical/psychological conditions: Psychotherapy or counseling history: Review of Systems: Describe fully. Use additional sheet if needed. WNL Head, ears, nose, throat Hearing Respiratory Cardiovascular Gastrointestinal Hernia Eyes Genitourinary Musculoskeletal Metabolic/endocrine Neuropsychiatric Skin Any other conditions ABNL Medications to be continued at school (please list dose and schedule for each medication) My examination finds the student named above to be in good health, free from contagion, and physically and emotionally qualified for a full program of study and sports. Yes No If no, please explain: Print or type name and address of examining physician Name Phone Number Street City State Country Zip Code [ Physician’s Signature (required) FORM: EXAMRETURN / DUE: 07.15.12 [ Date
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- Page 19 and 20: 2012-2013 STUDENT INJURY AND SICKNE
- Page 21 and 22: THIS LIMITED HEALTH BENEFITS PLAN D
- Page 23 and 24: Schedule of Medical Expense Benefit
- Page 25 and 26: OTHER Ambulance Services, when medi
- Page 27 and 28: 4. Drugs available over-the-counter
- Page 29 and 30: Home health care shall consist of,
- Page 31 and 32: Benefits for Postpartum Care If an
- Page 33 and 34: Benefits for Pain Management Benefi
- Page 35 and 36: 13. Immunizations, except as specif
- Page 37 and 38: Scholastic Emergency Services: Glob
- Page 39 and 40: [ suffield academy [ Suffield, Conn
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- Page 43 and 44: Since 1921 Since 1921 6078 • (860
- Page 45 and 46: 06078 • (860) 668-7315 • Fax (8
- Page 47 and 48: Dear Sufüeld Academy Parents and S
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[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
PHYSICAL EXAMINATION RECORD FOR RETURNING STUDENTS<br />
Please be thorough. Omission of k<strong>now</strong>n health problems can jeopardize a student’s health care <strong>and</strong> well-being. A physical examination must be filed each year<br />
before a student may participate in any part of the school program. Physical must be done within one year.<br />
NAME OF STUDENT<br />
First Name last Name Middle Name<br />
Blood pressure Pulse Asthma (preventative & emergency treatment)<br />
Height<br />
Weight<br />
inches<br />
pounds<br />
Allergies (please list)<br />
Immunizations since last physical:<br />
Current medical/psychological conditions:<br />
Psychotherapy or counseling history:<br />
Review of Systems: Describe fully. Use additional sheet if needed.<br />
WNL<br />
Head, ears, nose, throat<br />
Hearing<br />
Respiratory<br />
Cardiovascular<br />
Gastrointestinal<br />
Hernia<br />
Eyes<br />
Genitourinary<br />
Musculoskeletal<br />
Metabolic/endocrine<br />
Neuropsychiatric<br />
Skin<br />
Any other conditions<br />
ABNL<br />
Medications to be continued at school<br />
(please list dose <strong>and</strong> schedule for each medication)<br />
My examination finds the student named above to be in good health, free from contagion, <strong>and</strong> physically <strong>and</strong> emotionally qualified for a full program of study <strong>and</strong> sports.<br />
Yes No If no, please explain:<br />
Print or type name <strong>and</strong> address of examining physician<br />
Name<br />
Phone Number<br />
Street City State Country Zip Code<br />
[<br />
Physician’s Signature (required)<br />
FORM: EXAMRETURN / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
[<br />
Date
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