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SL]FFIELD ACADEMY - Suffield Academy
SL]FFIELD ACADEMY - Suffield Academy SL]FFIELD ACADEMY - Suffield Academy
FORM rs DunnvJur.v L5,201.1 SUf'ffnf,l AC,mBVfy Suffi eld, Connecticut 0 60 7 I ACKNOWLEDGEMENT OF SUFFIELD ACADEMY MEDICAL PHILOSOPHY Student 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 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 signature Date Student Signature Date 5t3UIt
FORM rs DUD BY JULY 15,2011 Sunnrnr,o ACADEMY Suffi e ld, C onnec ticut 0607 I PHYSICAL EXAMINATION RECORD FOR RE?UÀN/NG STUDENTS Please be complete. Omission of known health problems can jeopardize a student's health care and wellbeing. A physical examination must be filed each year beþre a student møy participate in any part of the school program. Physical must be done within one year. STUDENT'S FULL NAME: Date of Birth: Blood pressure Height \{eight inches pounds Pulse Asthma (preventative & emergency treatment) Allergies (pleaselist) Immunizations since last physical: Current medicaVpsychological conditions: Psychotherapy or counseling history: Review of Systems? Describe fully. Use additional sheet if needed. Medications to be continued at school: Please list dose and schedule for each medication) ABNL My exøminationlinds the student named øbove to be in good heølth,free from for øfull progrøm of study ønd sports. contøgion, and physically und emotionelly quaffied Yes No If no, please explain: Print or type name and address of examining physicfun: Phone number City Søte zip Physician's Signøture (Regu,itc!Ð Date of Bxam
- Page 1 and 2: SL]FFIELD ACADEMY Suffield, Connecc
- Page 3 and 4: 9. 10. 11. l2 *Student Health Insur
- Page 5: SUFFIELD Ac¿.nnn,ry Suffeld,CT 060
- Page 9 and 10: FoRM ¡s DUE BY JULY 15,2011 SUfT.I
- Page 11 and 12: IMPORTANT INFORMATION ABOUT INFLIJE
- Page 13 and 14: FoRM rs DUE JuLy ts,2ltl SUfflnf,l
- Page 15 and 16: EXPENSE C¡.InconIns 1. CASH BANK:
- Page 17 and 18: SUFFIELD ACEOEVTY Photo & Press Rel
- Page 19 and 20: SUFFIELDACADEMY GENERAL INFORMATION
- Page 21 and 22: The UPS Store Students Name Shippin
FORM rs DUD BY JULY 15,2011<br />
Sunnrnr,o <strong>ACADEMY</strong><br />
Suffi e ld, C onnec ticut 0607 I<br />
PHYSICAL EXAMINATION RECORD FOR RE?UÀN/NG STUDENTS<br />
Please be complete. Omission of known health problems can jeopardize a student's health care and wellbeing.<br />
A physical examination must be filed each year beþre a student møy participate in any part of the school program.<br />
Physical must be done within one year.<br />
STUDENT'S FULL NAME:<br />
Date of Birth:<br />
Blood pressure<br />
Height<br />
\{eight<br />
inches<br />
pounds<br />
Pulse<br />
Asthma (preventative & emergency treatment)<br />
Allergies (pleaselist)<br />
Immunizations since last physical:<br />
Current medicaVpsychological conditions:<br />
Psychotherapy or counseling history:<br />
Review of Systems? Describe fully. Use additional sheet<br />
if needed.<br />
Medications to be continued at school: Please list<br />
dose and schedule for each medication)<br />
ABNL<br />
My exøminationlinds the student named øbove to be in good heølth,free from<br />
for øfull progrøm of study ønd sports.<br />
contøgion, and physically und emotionelly quaffied<br />
Yes No If no, please explain:<br />
Print or type name and address of examining physicfun:<br />
Phone number<br />
City<br />
Søte<br />
zip<br />
Physician's Signøture (Regu,itc!Ð<br />
Date of Bxam
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