Order now and save! $920 after 8/15/12 - Suffield Academy

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suffield academy
[ Suffield, Connecticut / 860.386.4400
2012/13 student forms
ID#
date of birth
ACKNOWLEDGEMENT OF SUFFIELD ACADEMY MEDICAL PHILOSOPHY
NAME OF STUDENT
First Name Last Name Middle Name
All Suffield students, both returning and new, must have an annual physical. A physical completed after March 1 of this year is acceptable for the upcoming
school year. The completed form must be returned by the physician to the Health Center by July 15. If, for insurance constraints, you are unable to have a
physical completed and returned by July 15, please notify the Health Center with the date of the physical. Should this date fall after the start of school, a note
from the student’s primary care provider must be submitted to the Health Center stating that your daughter or son is cleared to participate in all school and
athletic activities until the time of the physical. No student will be allowed to participate in the above without a physical or note.
Prescriptions that are self-administered must be accompanied by written directions as to strength, dose, and duration by the student’s physician. Prescriptions
for controlled substance drugs must be kept at the Health Center. All prescription medication kept on campus must be checked in through the
Health Center. Medications that are to be kept in the dormitory will be noted in the medical record, and the Health Center will affix a label to the bottle
identifying that this is safe to keep in the dorm and is documented. Medication not checked-in is considered contraband, and the matter will be transferred to the
Dean of Students’ Office. A few medications (controlled and many psychotropics) are required to be kept in the Health Center and dispensed by the Health Center
staff. All medications must be brought to the Health Center within 24 hours upon arrival or return to school.
Any required immunizations that are not complete may be administered at the Health Center.
Please check electronic signature approval box (or sign) below to acknowledge you understand Suffield’s medical philosophy and that you have completed all the
medical forms to the best of your knowledge.
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.
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FORM: MEDICAL / DUE: 07.15.12
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