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2010-2011 Health Forms
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We are looking forward to the 2010-2011 school year at Brewster Academy. In preparation and for your convenience, health forms are posted below. To make it easier on families, we have created two files, one for new students and one for returning students. By selecting the appropriate link below, the forms will open in one PDF document for you to print, complete, and either mail or fax (603-569-7144) to the Health Center. The forms cannot be submitted online. International families have one additional PDF document to open (see Insurance link below), which is the application for ISM/ACE insurance.
To ensure that your student’s file is complete by the opening of school in September, please return the completed forms to the Health Center by July 15, 2010. Now is a good time to book your student’s yearly physical, as they often take weeks to schedule. We are aware that students cannot have a physical if it has been less than 12 months since their last physical. If the student's physical exam is not scheduled until after July 15, please mail all other forms and send a note with the date of the scheduled physical exam. Thank you. New Student Health Forms Returning Student Health Forms
Health Forms Checklist:___Health Center Policy (signature of parent and student)
Please read carefully and review with student. The policy outlines responsibilities of parents, students, and nurses.
___Medical Authorization (signature of parent).
Please make sure this form is accurate and legible ___Insurance (U.S. families must submit a copy of front and back of insurance card, card holder’s name and DOB). Please include copies of dental and prescription cards. International students must apply for ISM/ACE insurance. ___Medical History Form (signature of parent )
Accurate disclosure of medical history is necessary to provide appropriate care for your child. ___Immunization Record (required for new students only)
All required immunizations must be completed prior to student’s arrival at Brewster Academy. ___Medication Contract (signature of parent and student)
This form is required even if your student does not take prescription medication. If your child does take prescription medication, it is imperative that you review this together as there are consequences for missing meds. Parent and student need to sign and return the form but please keep the contract. ___Medication Information (to be completed by student’s physician if on meds) ___Physical Exam Form (Physician signature)
A yearly physical examination is required. Please forward exam report when completed. If a student arrives without having had a physical exam in the past 12 months an exam will be scheduled with the school physician. The charge will be $100 in addition to the cost of the exam. ___Flu Vaccine Permission Form (signature of parent)
Influenza vaccine is required and can be administered on campus in the fall. ___Informed Consent for Counseling Services (signature of parent and student)
If your child is taking any prescription medication, please mail it directly to the Health Center prior to your student’s arrival. If this is not possible, you can bring the medications in their original packaging directly to the Health Center when you bring your student to school. No medications will be accepted at the Health Services registration/orientation table in the Smith Center. Please do not give any medications to your student to bring to the Health Center. Please contact the Health Center with any questions or concerns so we can work together to support your child’s health needs.We look forward to seeing you in September. Brewster Academy Health Center 603-569-7121
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