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About St. George's School
Only 20 minutes from both the Airport and downtown,  St. George’s School  lies in one of the most beautiful natural settings and in one of most beautiful cities in the world.  Next to the 1800 acres of Pacific Spirit Park it provides a spectacular and safe environment for learning.
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2011 COMMON MEDICAL HISTORY FORM

Please note that the information contained herein is considered confidential and will only be shared with the Assistant Director and medical personnel in the event of a medical emergency. No person shall be denied entry based on the following information. 

The forms can also be found online here: 2011 Medical History, 2011 Medical Consent, 2011 Informed Risk Document

Please print and forward or mail these to our office.


As the parent or legal guardian of the participant, I do hereby consent to the administering of medical treatment and immunizations to the said student while in the care of the Summer at St. George’s Program and its employees, provided that such medical treatment and immunizations are found to be necessary or advisable in the opinion of the medical advisers to the Summer at St. George’s Program for the well being of said student and the medical treatment and immunizations are performed by those employees of  the Summer at St. George’s Program or such others at the request of the Summer at St. George’s Staff, who are properly qualified to perform such medical treatment and immunizations.

We acknowledge that St. George’s Summer Programs provides short term medical coverage for residential international students that includes the costs of immediate medical attention during their stay at St. Georges.  This medical insurance coverage does not apply to medical services after our child leaves Canada.  In addition, we recognize that as parents that if our child(ren) has  pre-existing and/or on-going medical conditions we would need to inform the school before attending the camp to confirm coverage.

We hereby further authorize the Summer at St. George’s Program by its lawful representatives, for as long as our son/daughter is attending the program at the School, to enter and execute on our behalf such consent documents or other documents as may be required by medical practitioners, health care professionals, hospitals or the City of Vancouver Health Department in connection with the medical treatment and immunizations of the said student.

DATE:
PARTICIPANT'S NAME * :
ADDRESS * :
APT#
CITY:
COUNTRY:
HOME PHONE:
BUS. PHONE:
PARTICIPANT'S BIRTHDATE (DD/MM/YEAR):
DOCTOR'S NAME * :
DOCTOR'S PHONE * :
B.C. CARE CARD PERSONAL HEALTH NUMBER:
OTHER HEALTH/MEDICAL INSURANCE:
NUMBER:

Are you subject to any of the following:

Arthritis Ear Trouble Kidney Trouble Sleep Walking Epilepsy
Motion Sickness Tonsillitis Boils Fainting Nightmares
Convulsions Bronchitis Frequent Colds Skin Disease Rheumatism
Hysteria Sinus Trouble Heart Condition Diabetes Headaches
Nose Bleeds High Blood Pressure     Other

Do you have any specific joint or bone problems? Yes    No

If yes please explain:

Do you have any allergies?

Foods Please Name
Insect Stings Type
Drugs Please Name
Environment/ hayfever Name Cause
Skin Rash Name Cause
Asthma 1. Stress induced     2. Exercise Induced
Please explain specific treatments or drugs given for any above allergic reactions.
Are there any psychological (ie. fear of water, heights) or physical conditions preventing the student from actively participating in the swimming and sports programs?Please explain
Swimming level: Non-swimmer Weak Intermediate Strong
When was the last time this student had a TETANUS inoculation or booster (d/m/y)?
(must be within the last 10 years, if joining our program)
EYESIGHT: Excellent Good Fair Poor Glasses Contacts
Have you been under a DOCTOR’S CARE in the last 12 months: Yes No
If YES, give details:
Have you had any MAJOR ILLNESSES, INJURIES, or OPERATIONS:
Are you taking any PRESCRIPTION or NON- PRESCRIPTION DRUGS: Yes No
Please specify:
Name of drug
Reason for taking drug
*all drugs and medicines are registered and administered by our nursing staff or designate

IN CASE OF EMERGRNCY, CONTACT (in Canada):

NAME #1:
ADDRESS:
RELATIONSHIP:
PHONE:
NAME #2:
ADDRESS:
RELATIONSHIP:
PHONE:

All of the above information is accurate as of today’s date. If there are any changes between now and the program date I agree to contact Summer at St. George’s with updated information.

DATE:
PARENT/GUARDIAN’S SIGNATURE:
PARENT/GUARDIAN’S PRINTED NAME:

Please click on Submit once; application may take a few minutes to transmit
©2008 by St. George's School 3851 West 29th Avenue, Vancouver, BC, Canada V6S 1T6 | Tel: (604) 222-5810 | email: info@stgeorges.bc.ca