First Name Surname

HAMILTON BOYS’ HIGH SCHOOL

Argyle HouseMedical Information and Permission forms for

Hamilton Boys’ High School, Private Bag 3201, Waikato Mail Centre, Hamilton 3240 Ph. +64 7 853 0437 argyle@hbhs.school.nz www.hbhs.school.nz

“Sapiens fortunam fingit sibi” - A wise man carves his own fortune

Hamilton Boys’ High School Argyle House Enrolment Form

2. FAMILY DETAILS

MOTHER

ADDRESS

POSTCODE

SURNAME

FATHER

POSTCODE

MOBILE

SURNAME

PHONE (Work)

MOBILE

PHONE (Work)AREA CODE

PHONE (Home)AREA CODE

AREA CODE

AREA CODE

MOBILE

PHONE (Work)

PHONE (Home)AREA CODE

PHONE (Home)AREA CODE

Mrs Ms Miss (please select)

EMERGENCY CONTACT’S NAME

ADDRESS

This form must be completed with your application for a position in the Hostel. This form will be retained in the hostel. All students at Argyle House are enrolled as patients at Hamilton East Medical Centre. A photocopy of this form will be passed on to the Hamilton East Medical Centre should the need arise.The information given by you will be used solely for the purpose of

providing appropriate medical care to your son. The information will not be disclosed by the school to anyone other than an authorised medical practitioner who is attending to the health needs of your son.

Argyle House Confidential Medical Information and Permission forms

DATE OF BIRTH

1. STUDENT DETAILS (Please complete all sections)

ADDRESS

ADDRESS

D D M M Y Y Y Y

CHRISTIAN NAMES CHRISTIAN NAMES

SURNAMEFIRST NAME MIDDLE NAME(S)

“Sapiens fortunam fingit sibi” - A wise man carves his own fortune

3. MEDICAL INFORMATION

4. MEDICAL HISTORY

COMMUNITY SERVICES CARD YES NO If yes please attach a copy

(If yes please specify)YES NO

MEDICAL INSURANCE YES NO

A ‘verified’ copy of Immunisation history must be provided.Either a copy from “Well Child Book” or Doctor’s verification.

CURRENT MEDICAL CONDITIONSPlease outline any medical condition which your child has and explain the appropriate course of action that Hostel staff should follow if he should experience the condition whilst at Argyle House.

DETAILS OF CURRENT MEDICATIONHas your child had any of the following conditions: (Give details and state age when it occurred if possible)

Does your son suffer from any allergies to medicines/foods/plants/insect bites or stings?

Headaches Asthma

Measles Earache

German Measles Bronchitis

Diptheria Frequent colds

Pneumonia Glue ear

Whooping Cough Phobias

Rheumatic Fever Tonsilitis

Mumps Skin disorders

Hepatitis Bed wetting

Poliomylitis Heart problems

Scarlet Fever Epilepsy

Leptospirosis Others

Tuberculosis

Sinustis

Hay fever

Hamilton Boys’ High School Argyle House Enrolment Form

Hamilton Boys’ High School, Private Bag 3201, Waikato Mail Centre, Hamilton 3240 Ph. +64 7 853 0437 argyle@hbhs.school.nz www.hbhs.school.nz

4. MEDICAL HISTORYFAMILY HISTORYIs there any family history of chronic medical conditions such as heart disease, asthma, tuberculosis, epilepsy?

SPECIALIST MEDICAL CARE

Permission for a staff member of Argyle House to administer prescription drugs obtained from the chemist or as prescribed by a doctor

Permission for a staff member of Argyle House to administer: Antihistamine Ibuprofen Panadol

For other medicine for a staff member of Argyle House to administer, please state _________________________________________________

for condition _________________________________________________________________________________________________________

Permission for my son to be attended by a doctor or taken to a hospital if the supervising staff of Argyle House or School Nurse consider it necessary. I hereby authorise the supervising staff in charge to permit my child to be given general anaesthetic and to be operated on in the case of a medical emergency if such treatment is considered necessary by a qualified medical practitioner. This permission is given provided that every effort will be made to contact me personally before any decision is made to operate. NB Such a decision will be made by staff only where there is a medical emergency and where every possible effort to contact me has failed.

(If yes please specify)YES NO

SIGNATURE OF PARENT /GUARDIAN

DATE

SIGNATURE OF PARENT /GUARDIAN

DATE

SIGNATURE OF PARENT /GUARDIAN

DATE

Dermatology

Haematology

Neurology

Orthopaedics

Cardiology

Gastroenterology

Mental Health Services

Ear, Nose and Throat (ENT)

Immunology

Occupational Therapy

Oncology Rehabilitation Services

Other (please state): __________________________

Please give details of any specialist(s) attending your son and provide their name(s) and address(es):

____________________________________________________________________________________________________________________