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SL]FFIELD ACADEMY - Suffield Academy
SL]FFIELD ACADEMY - Suffield Academy 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
FoRM ¡s DUE BY JULY 15,2011 SUfT.IELD ACÁ,DEMY SUT'FIELD, CONNECTICUT 06078 AUTHORIZATION FOR THE ADMINISTRATION OF PRESCRIPTION MEDICINE BY SCHOOL PERSONNEL Any medication prescribed for a student must be reported to the Health Center. This form must be completed for all controlled substances, mood altering medications and any other medication to be dispensed by school personnel. Connecticut State statute requires a physician's or dentist's written order and the parent's/guardian's authorization for a nurse to administer prescription medicine. Medications must be in pharmacy-prepared blister-pack containers and labeled with the student's name, name of the drug, strength, dose, frequency, physician's or dentist's name and date of the original prescription. The physician's name and order must be the same on the authorization form and prescription bottle. All prescriptions may be included on this form. Photocopies of this form are acceptable. PHYSICIAN'S OR DENTIST'S ORDER: Name of student: Diagnosis: I have evaluated and examined the student on (date) and plan to reassess the medication and treatment plan on (date) Drug: (name, dose, frequency and method of administration) Medication shall be administered from: (date) to: (date) Relevant side effects to be observed, if any: lf there are side effects, give plan for management: Is this a controlled drug? Yes Physician's/Dentist's Signature: No If yes, DEA # Date: (Print or type) Name: Address: Phone: Fax: 5-27.tI
- Page 1 and 2: SL]FFIELD ACADEMY Suffield, Connecc
- Page 3 and 4: 9. 10. 11. l2 *Student Health Insur
- Page 5 and 6: SUFFIELD Ac¿.nnn,ry Suffeld,CT 060
- Page 7: FORM rs DUD BY JULY 15,2011 Sunnrnr
- 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 ¡s DUE BY JULY 15,2011<br />
SUfT.IELD ACÁ,DEMY<br />
SUT'FIELD, CONNECTICUT 06078<br />
AUTHORIZATION FOR THE ADMINISTRATION OF PRESCRIPTION MEDICINE<br />
BY SCHOOL PERSONNEL<br />
Any medication prescribed for a student must be reported to the Health Center. This form must be completed<br />
for all controlled substances, mood altering medications and any other medication to be dispensed by school personnel.<br />
Connecticut State statute requires a physician's or dentist's written order and the parent's/guardian's authorization<br />
for a nurse to administer prescription medicine.<br />
Medications must be in pharmacy-prepared blister-pack containers and labeled with the student's name, name of the<br />
drug, strength, dose, frequency, physician's or dentist's name and date of the original prescription. The physician's name<br />
and order must be the same on the authorization form and prescription bottle.<br />
All prescriptions may be included on this form. Photocopies of this form are acceptable.<br />
PHYSICIAN'S OR DENTIST'S ORDER:<br />
Name of student:<br />
Diagnosis:<br />
I have evaluated and examined the student on (date)<br />
and plan to reassess the medication and<br />
treatment plan on (date)<br />
Drug: (name, dose, frequency and method of administration)<br />
Medication shall be administered from: (date)<br />
to: (date)<br />
Relevant side effects to be observed, if any:<br />
lf there are side effects, give plan for management:<br />
Is this a controlled drug? Yes<br />
Physician's/Dentist's Signature:<br />
No If yes, DEA #<br />
Date:<br />
(Print or type) Name:<br />
Address:<br />
Phone:<br />
Fax:<br />
5-27.tI
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