Infirmary form as at 11 november 2013

INFIRMARY INFORMATION

Photocopies of your medical aid card, as well as ID of main member
of scheme must accompany this form.
Kindly complete this form (block letters) in respect of your daughter and hand it in on the first day of
the school year. This information is vital for either a day girl or boarder should an emergency arise.
Surname of learner: ……………….……….…….…………………………………Grade: …………….
Name of learner: ………………………………………………………Hostel / Day Girl: ………………
Birth date: ………………….………….
Main member of Medical Scheme – Surname and initials:…………………….………………………. Name and Number of Medical Aid Scheme: ….…………………………………………………………. Father Surname and Initials: ………………………………………………………………………………. ID: …………………….….Tel No: ……………………………… Cell No: ….…………………………… Occupation: ………………………………………… Employer: ………………………………………… Mother Surname and Initials: ……………………………………………………………………………… ID: …………………….….Tel No: ……………………………… Cell No: ….…………………………… Occupation: ………………………………………… Employer: ………………………………………… Immunized against: Diphtheria:……. Tetanus:.…… Measles:.……Poliomyelitis:.……BCG ……. Has she resulting disabilities: Yes / No Is her heart in good condition: Yes / No Is she subject to eczema? Yes / No : caused by ……………………………………………………. Is she subject to hay fever? Yes / No : caused by …………………………………………………. Is she subject to asthma? Yes / No : caused by ……………………………………………………. Has she any other allergies? If so, give details. ……………………………………………………. Please give details of operations to date: ……………………………………………………………. ……………………………………………………………………………………………………………… Is there any reason why she should not take part in a specific sport: ……………………………… If so, please furnish a doctor’s certificate. Tel: (051) 401 5700, Fax: (051) 401 5703
Please note it is vital for you, as parents, to let us know if your daughter is
allergic to anything: eg. bee-stings, peanuts, etc. We, as a school, cannot
be held responsible if something happens as a result of her allergy.
If her allergy is life-threatening, please supply the office with her medication.

Allergy: …………………………………………………………………….
Please circle any of the under-mentioned illnesses she has had.
Bronchitis

Has she had any other illnesses not mentioned above? Please give details:
…………………………….…………………………………………………………………………………
I, parent of …………………………………………………. give permission to the hostel supervisory
staff to take my child to the doctor in cases of emergency. I understand that they will still contact me
before taking my daughter to the doctor. Please note that the school will not be held
responsible for any costs if no medical aid is available.
…………………………………………
…………………………………………….
The information requested below applies to boarders only:

Please note:
-
It is advisable to open a chemist account for your daughter at any chemist of your choice for medicines, toiletries, etc. This medical information will be kept on file and updated yearly. Please inform the office of any changes of address, Medical Aid and telephone numbers. This is of the utmost importance if immediate contact with you is required in the case of an emergency. In order to prevent accidents, it is strictly forbidden for a learner to keep any medication in her cubicle. All medicines must be kept under lock and key in the infirmary.
I, parent of ………………….………………………………. give the school permission to add any
medical levies, additional costs or prescription costs to my school account. I understand that
the Infirmary Sister will contact me regarding these costs.
……………………………………………
…………………………………. Urgent Notice to All Hostel Pupils

MEDICATION:
According to legislation, we are not allowed to dispense any medication to learners.
We would appreciate if, at the beginning of the year, you could issue your child with the following:
-
1 tube of Bactroban or Betadine antiseptic ointment 1 small bottle of Dettol or Savlon antiseptic Tablets: Headache, period pains or any other, eg. muscle etc Tablets: Sinusitis, colds, flu and sore throat Tablets: Stomach cramps and diarrhoea (Buscopan, Lomotil or Gastron)
Every learner needs her own infirmary kit in a container which is clearly marked with a sticker
(name, surname, Grade). A 2 litre ice cream container will do. No paper- or plastic bags please!)
The kits are locked up in the infirmary and we issue your daughter with her own medication.

PLEASE NOTE: If you do not send a kit, we will NOT be able to give your daughter any
medication.
WHEN NECESSARY TO SEE A DOCTOR:
The Infirmary Manager WILL MAKE AN APPOINTMENT for AFTER school hours.
The learner will be informed, and transport will be arranged.
Please make sure that enough money is available.
Options:
1.
Medical Aid (provide your daughter with necessary details) Deposit money into St Michael’s account. Contact Rosemary van Niekerk (051 401 5720). Arrange with Medicross (Tel: 051 4060230) You are welcome to contact me during school hours. Kind regards Mrs Rina Prinsloo (Tel: 051 401 5719; Cell: 076 416 7958)

Source: http://dev.stms.co.za/wp-content/uploads/2014/02/Infirmary-Form-as-at-11-November-2013.pdf