Please return to health center/infirmary

PLEASE RETURN TO
SAN JOSE CAMPUS HEALTH CENTER
THE BOLLES UPPER SCHOOL
EMERGENCY MEDICAL INFORMATION FORM
Due August 1, 2012
STUDENTS MAY NOT ATTEND SCHOOL WITHOUT THIS FORM ON FILE
This form must be filled out each year. Last year’s form is not valid.
STUDENT’S NAME ____________________________________________________________________ GRADE ______ Preferred Name _________________________________ Student Number ______________________________________ Birth Date ______/______/______ Social Security Number ______/_____/________ Address ____________________________________________________________________________________________ CONTACT PHONE NUMBERS: Please place an asterisk next to the first phone number we should call. Father’s Name _______________________________________________________________________________________ WorkPh: ___________________ HomePh: _________________ CellPh: _______________ Beeper: _________________ Mother’s Name ______________________________________________________________________________________ WorkPh: __________________ HomePh: __________________ CellPh: ______________ Beeper: _________________ Legal Guardian: (Student lives with) ______________________________________________________________________ EMERGENCY CONTACT NUMBERS (to be used only if parents cannot be reached) 1. Name ___________________________________________ Relationship ______________________________________ WorkPh: _________________________________________ HomePh: _______________________________________ 2. Name __________________________________________ Relationship _______________________________________ WorkPh: _________________________________________ HomePh: _______________________________________ Names and Grades of siblings at The Bolles School ___________________________________________________________________________________________________ MEDICATIONS WHICH MAY BE ADMINISTERED BY THE SCHOOL. PLEASE CHECK THE MEDICATIONS PERMITTED. NO MEDICATIONS WILL BE GIVEN UNLESS INDICATED ON THIS FORM BY PARENTS.  Decongestant (Sudafed or Suphedrine PE) CONSENT FOR EMERGENCY HEALTH CARE
(To be completed in black ink by parent)

STUDENT’S NAME ____________________________________________________________________ GRADE ______
Please list all allergies (i.e., medication, environmental, insects, food): _______________________________________ ___________________________________________________________________________________________________ Please indicate any special needs or conditions of which we should be aware: _________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please list any medication your child takes on a regular basis: _____________________________________________ ___________________________________________________________________________________________________ MEDICAL/HOSPITALIZATION INSURANCE (We provide International students with insurance.) Name of Insurance Company ___________________________________________________________________________ Claims Address ______________________________________________________________________________________ ID/Policy # ______________________________________ Group # ____________________________________________ Policyholder’s Full Name ______________________________________________________________________________ Policyholder’s Date of Birth ________________________ Policyholder’s Social Security # _________________________ Does the insurance company require pre-authorization? __Yes __No Telephone # ( ) _______________________ PREFERRED HOSPITAL _____________________________________________________________________________ PHYSICIAN _____________________________________________________ PHONE ___________________________ ORTHOPEDIST __________________________________________________ PHONE ___________________________ DENTIST ________________________________________________________ PHONE ___________________________ ORTHODONTIST ________________________________________________ PHONE ___________________________ The Bolles School is required by HIPAA (the Federal Health Insurance Portability and Accountability Act) to preserve the privacy of your child’s health information. In accordance with this policy, access to all student health forms is limited to the School nurse or administrative staff, and is only utilized for the safety and protection of your child or in an emergency. I authorize the School nurse or the faculty/staff of The Bolles School to obtain such professional medical/surgical care or hospital services as may appear to be necessary or desirable for the protection of the health or life of my minor child, named above. Any person rendering health care pursuant to this authorization shall be entitled to treat this consent as having been given to such person. I further understand that The Bolles School will, in any event where emergency room or hospital treatment for a student is indicated, use due and prompt diligence to notify and consult with a parent or guardian. I further agree to pay and to hold The Bolles School harmless on account of any reasonable medical, dental, hospital, or other related charges incurred on behalf of the patient. Signature of Parent/Guardian ___________________________________________________ Date ____________________

Source: http://www.bolles.org/s/864/images/editor_documents/pdfs/health_forms/2012-13-bolles-us-emergency-medical-form.pdf