SL]FFIELD ACADEMY - Suffield Academy

FoRM rs DUE By JuLy 15, 201 1
SUITIELD ACADEMY
Suffield, C onnect icut 0607 8
PERMISSION FOR MEDICAL OR SURGICAL TREATMENT
Treatment Waiver
This Jorn musl be signed by the student's parent or legal guardian so that appropriate diagnosß and treelment mny be promptly adminislered and so thal no
unnecessary delnys will occur in case oJ a medical or surgical enlergency. In the event of an emergency, every atternpl will be made lo contact and fully inform llte
parenls or legal guardian.
I hereby authorize the physician (M.D.) of Suffield Academy, Suffield, Connecticut, to procure and adminisler qnj care, medical or surgical, and an1, hospi¡o¡ çar.
deemed necessary to reslore lrcallh to my son or rlaughter.
M¡ son or dnughter has my permission to selJ-administer any medication, ordered by the school physician or consulting physician, with the approval of the school
nurse. The Headmsster or his designee nwy give permßsion for surgical or medical lrealment Íor my son or daughter in the event l/we cannol be conlacted.
I authorize the school nurse or cuthoriTed faculty member 10 admin¡ster medicalions prescrìbed by the school physician or consulting physician. I further authorize lhet
medical inJormation be released to faculty and advisors on a need to know basis.
STUDENT'S FULL NÀME:
(Please Print)
Date of Birth
Middle
Student's Social Security Number
List Any Known Ä,llergies;
Student's Signalure (if 18 or older):
Parent or Guardian's Signature: (if student is under 18)
Relationship to Studen(
Signature
Signature
Date
Please lype or print all inJormnlion requested below
Parents'Contact
Information
Name
Street Address
City/Sâre/Zip
Cell Phone
Relationship to Student
Home Telephone
Business Telephone
E-mail
In case the PARENT named above cannot be reached, please contâct:
Name
Street Address
CitylSt*elZip
Relationship to Student
Home Telephone
Business Telephone
Medical Insurance Information
ls a referral needed:
Name of Insurance:
Address to mail claim form:
Name of Subscriber:
-
PCP: Name
Phone:
Insurance Company's Phone Number:
Subscriber's Date of Birth
Subscriber's Place of Employment
Insurance Identification Number
Subscriber's Social Security number:
DR:5.24.1I
XXXPLEASE PROVIDE AN ENLARGED COPY oF THE FR0NT AND BACK OF ALL INSURANCE CANNSXXX
Please do not staple forms