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 [email protected] 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 [email protected] 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):
____________________________________________________________________________________________________________________