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Microsoft word - combined chs health profile - 2008.doc

HEALTH PROFILE and PARENT CONSENT FORM
All sections of this form must be completed as part of the enrollment application for Caronport High School.
Although a medical exam is not required, it is advised that all students have medical, dental and eye exams as well as all routine immunizations up to date prior to their arrival on campus. Students competing in Cougar Athletics may be required to have a medical exam. You will be notified if this is necessary. Section A: Personal Data Anticipated Start Date: (DD/MM/YY)
Student’s Name: ____________________________________________
Name of Parents/Legal Guardians:
Father:____________________________________ Mother:___________________________________ Same as Home Phone:___________________________ Home Phone: ___________________________ Work Phone:___________________________ Work Phone: ____________________________ Street/Box number:______________________ Street/Box number:_______________________ City:__________________________________ City:___________________________________ Province:____________________________ Province:____________________________
Code:__________________________ Postal Code:__________________________
If applicable, who has legal custody: ________________________________________________
Emergency Contacts:
1) Name:__________________________________ 2) Name:__________________________________ Relationship to the student:________________ Relationship to the student:________________ Phone:___________________________ _____ Phone:___________________________ ______
Section B: Medical Information

Provincial Health Services number: _____________________________ Province: _________________
(International students must apply upon arrival to campus for a Saskatchewan Health Card - No charge)
Additional group medical insurance and/or private insurance:
_______________________________ _______________________ _________________________
Name of Plan
Name of family physician: ____________________________________ Phone: ( ) ______________ ☺ Allergies: (Please specify) NO YES Name:______________________________________________ NO YES Kind:_______________________________________________ NO YES Kind:_______________________________________________ What type of reaction? __________________________________________________________________ If the reaction is severe, does the student have an epi-pen or a medic-alert bracelet? NO YES Asthma (severity, inhalers, etc.) __________________ Diabetes (type) _____ (insulin) __________________ Hospitalization /Surgery (in past year) ________________________________________________
Other(Please specify): _____________________________________________________________
Other(Please specify): _____________________________________________________________ Inpatient program or Psychiatric care (in past year) ______________________________________ ☺ Is the student currently taking medication? NO YES If so, please provide name and dosage: Medication: _____________________ Dosage:___________________________ If your child needs medication at school or emergency procedures (allergy medicine, inhalers, etc.) please contact Health Services as a second permission form must be completed. ☺ Please indicate which medications can be given by the Residence Life staff as needed: Other: __________________________________________________________________________
Section C: Parental Consent
To be completed by parent/legal guardian if student is under the age of 18.
I, as the undersigned parent/legal guardian, do hereby give consent for _________________________________________
to undergo all necessary medical examinations, diagnostic tests, x-rays, and treatments including local anesthetic that will be required
in the course of diagnosis, examination and treatments of his/her illness or condition while a student at Caronport Schools, with the
understanding that Residence Life staff may at that time give consent for treatment. Furthermore, this information may be forwarded
to those individuals involved in insuring the provision of adequate health care while attending Briercrest (i.e. sports and ministry
teams). In so giving this consent, the applicant and parent/legal guardian do jointly and severally remise, release and forever discharge
Caronport Schools and further do jointly and severally indemnity and save harmless the said Caronport Schools from all manner of
action or actions, cause or causes of action, suits, debts, dues, sums of money, claims, charges, liabilities, expenses, damages, losses
and demands whatsoever at law or in equity that they may suffer or otherwise incur as a result of, in connection with, or in relation to
any such medical examinations, diagnostic tests, x-rays and treatments as referred to above, provided that Caronport Schools and its
employees, agents, representatives and/ or professional advisors have acted or omitted to act in good faith.
** NOTE: Information collected on this file will be used to provide care to you during your enrollment at CHS. We are committed to
ensuring that your personal information remains confidential and private. This information will be disclosed, as necessary, only for the
purposes that are considered reasonable in the particular circumstance – e.g. health care numbers and allergies to sports teams, your
personal physician upon request, in cases of threat of harm to self or others. It will not be used to disclose personal information for any
purpose other than that for which it was collected, or if you consent to specific disclosure. Only Caronport Schools and Prairie South
School Division No. 210 authorized employees will have access to your personal information and appropriate controls are in place to
ensure security of this information. Your file will be kept in compliance with Provincial regulations(usually 7-10 years). After this
time, your file will be destroyed. You may at any time update, amend or request a copy of this document.
To the best of my knowledge all information I have given on this form is complete and true.
Signed:_______________________________________ Date:_____________________________
Signature of Parent or Legal Guardian (if student is under 18 years of age) Signed:_______________________________________ Date:_____________________________ Student

Source: http://www.briercrest.ca/media/181170/CHS%20Health%20Profile.pdf

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