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About
Overview
Buxton At A Glance
Our People
Employment
Annual Occupant Notification Form
Academics
Overview
Curriculum
Post-Graduate Program
Urban Intensive
Academic Support
Life After Buxton
Admissions
Overview
Tuition & Financial Aid
Apply Now
Student Life
Residential Life
Activities
Arts
Athletics
Work Program
About Williamstown
News & Events
Alumni News and Events
News
Calendar
Summer Programs
Support Buxton
Connect
Login
Medical Form
Home
»
Medical Form
Medical Information Form 2023-2024
Required form, one per student. Due 8/1/22.
EMERGENCY CONTACTS
Student Name
*
First
Last
Date of Birth
Parent Name
First
Last
Home Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Phone Number
Emergency Contact 1 (in addition to parents)
*
First
Last
To be contacted in the event of an emergency, if parent/guardian cannot be reached.
Phone Number
Emergency Contact 2 (in addition to parents)
First
Last
To be contacted in the event of an emergency, if parent/guardian cannot be reached.
Phone Number
Medical History
Immunizations current?
*
If no, please fill out a vaccine exception form.
Yes
No
Glasses
Yes
No
Contacts
Yes
No
Hearing problems
Yes
No
Orthodontics presently
Yes
No
Skin problems
Yes
No
Scoliosis
Yes
No
Surgeries
Yes
No
Seizures
Yes
No
Depression
Yes
No
Anxiety
Yes
No
Anger Management issues
Yes
No
Panic disorder/issues
Yes
No
Phobias
Yes
No
ADD/ADHD
Yes
No
Learning difficulties
Yes
No
Sleeping problems
Yes
No
Eating problems/disorders
Yes
No
History of /current professional counseling
Yes
No
Need for continued therapy
Yes
No
Diabetes
Yes
No
High blood pressure
Yes
No
Heart problems
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Restriction on physical activities
Yes
No
Is your student at increased risk for COVID-19?
Yes
No
If you answered YES to any of the above, please explain
KNOWN ALLERGIES: Please list any allergies and the allergic response:
Buxton School Over-the-Counter Medications/ Annual Influenza Vaccination
Please Indicate which topical or oral OTC medications you do NOT want administered to your child
Antibiotic cream (i.e. Bacitracin Cream Polysporin)
Hydrocortisone cream
Benadryl Cream
Cough Drops
Cough Syrup
Ibuprofen (i.e. Advil, Motrin)
Acetaminophen (i.e.Tylenol)
Antacid
Cold Medication
Antihistamine
ANNUAL INFLUENZA IMMUNIZATION
*
I give permission for my student to receive an annual influenza vaccination
I do not give permission for my student to receive an annual influenza vaccination
Buxton School hosts an on-campus flu shot clinic annually (generally in late September or early October). Students are encouraged to sign up to receive the flu shot on campus if they have not yet received their annual flu shot. Parental permission is required for students under 18.
Parent/guardian electronic signature
*
Today's Date
CURRENT HEALTH INSURANCE INFORMATION
Student's name
*
First
Last
Health Insurance Company
*
Policy number
*
Subscriber’s name
*
Subscriber’s birthdate
*
Health Insurance Card
*
Max. file size: 300 MB.
Please upload images/copies of your student's health insurance card - front & back. Thank you!
Prescription Card
Max. file size: 300 MB.
If your student's prescription insurance is different than their medical insurance, please include photos of the front & back of the prescription insurance card.
Email
This field is for validation purposes and should be left unchanged.
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