KES Medical Form 2013 Boarders.pdf - King Edward VII School

KING EDWARD VII SCHOOL
PARTICULARS OF BOARDING HOUSE PUPIL
& MEDICAL FORM
BOARDER’S SURNAME : INITIALS : FIRST NAMES :
GRADE :____________ AGE: ____________ DATE OF BIRTH : ID NO :
PARENTS: MARRIED / DIVORCED (Delete which is not applicable)
If divorced, is Mother married again YES / NO If divorced, is Father married again YES / NO
(Delete which is not applicable)
Who does your son reside with ______________________________________________________________________________
SURNAME OF MOTHER: __________________________________________________________ INITIALS: ______________
ADDRESS OF MOTHER: __________________________________________________________________________________
CELL: _________________________________HOME : ______________________ BUSINESS: ________________________
EMAIL: _________________________________________________ FAX: _________________________________________
SURNAME OF FATHER: ___________________________________________________________ INITIALS: ______________
ADDRESS OF FATHER: ___________________________________________________________________________________
CELL: _________________________________HOME : ______________________ BUSINESS: ________________________
EMAIL: __________________________________________________ FAX: _________________________________________
RELATIVE : ____________________________________________ FRIEND : ________________________________________
ADDRESS : ____________________________________________ ADDRESS : _______________________________________
____________________________________________
_______________________________________
PHONE : (H) PHONE : (H)
PHONE : (B/Cell) PHONE : (B/Cell)
MEDICAL SCHEME : _____________________________________________________________________________________
PLAN TYPE : FUND NO. :
PERSON RESPONSIBLE FOR ACCOUNT : ___________________________________________________________________
I.D. NO : _____________________________________ EMPLOYER : _______________________________________________
A Certified photostat copy of both sides of medical aid card must accompany this form.
PARTICULARS OF INFECTIOUS DISEASES YOUR SON HAS HAD (Insert YES or NO)
WHOOPING COUGH : ______ MEASLES : ______ MUMPS : _____ CHICKEN POX : _____ GERMAN MEASLES : _______
OTHER ILLNESSES : ____________________________________________________________________________________
ALLERGIES :
MEDICINES : _________________________________________ INJECTIONS : _____________________________________
TABLETS : __________________________________________ FOOD : ____________________________________________
INOCULATIONS AND VACCINATIONS RECEIVED BY PUPIL :
DIETARY REQUIREMENTS
NOTE FROM DOCTOR OR RELIGIOUS LEADER REQUIRED FOR DIET RESTRICTIONS
P.T.O.

MEDICAL TREATMENT AND CONSENT
Learner’s Name:
I understand that the Boarding House fees I am paying do not cover the cost of medical treatment. (The
Boarding House Staff take care of the home nursing to the best of their ability, making use of the normal
home medications which are available in the Boarding House.)
Dr Baxter, the School doctor, has his rooms at 15A Bradford Road, Bedfordview, and may be called upon if
the boarders require a consultation. Any medication necessary is for the account of the parents.
In the event of illness or an accident where, in the opinion of the responsible Housemaster, medical
treatment will be necessary for my child and where I cannot be notified in time, I wish the following doctor
to be called:
Doctor Name :
Telephone No.
Home:
In extremely urgent cases of illness or accident where I cannot be consulted in time, I give my consent that
(i)
the Senior Housemaster, or his deputy, may take the necessary steps to call the best available
Doctor or take the child to hospital, and should a practising physician regard an emergency
operation essential, he may give his permission for it on my behalf;
(ii) I will be responsible for the payment of all costs connected to or associated with any medical and /
or hospital care required in respect of my son.
SIGNATURE :
WITNESS : 1.
2.