Chautauqua Summer Schools

OF THE FINE AND PERFORMING ARTS

Residence Hall Application

Please complete and return to: Chautauqua Institution Schools Office, Box 1098 Chautauqua, NY 14722 smalinoski@ciweb.org fax: 716-357-9014 Please print or type:

Chandler Theophilus A Name _______________________________________________________________________________

last first initial

Sex

Male

Female

243-73-5455 Social Security Number ____________________________

06/23/2012 08/14/2012 Dates of Attendance _______________ to _________________

In Case of Emergency Notify:

Instrumental Program ________________________

Father Francis Chandler Name____________________________________________________Relationship__________________ 207 Murray St. Address______________________________________________________________________________ Hillsborough NC 27278 City ________________________________________ State __________ Zip ______________________
Home Phone (

919-732-1982 ) ________________________Cell Phone (

919-593-6884 ) _____________________________

knarfhill@embarqmail.com E-mail _______________________________________________________________________________

Medical Information: I am covered by medical insurance: Yes No

Company _______________________________________ Policy Number ________________________ Primary Care Physician __________________________ Address ________________________________
PLEASE INCLUDE COPIES OF YOUR HEALTH INSURANCE AND PRESCRIPTION CARDS (IF ANY).

If no, I understand that I may be required to pay in advance for medical diagnosis or treatment. Blood type _________________ (optional but good information for us to have) Allergies _____________________________________________________________________________ Current medications ____________________________________________________________________

Health History: (If 18 or over you may fill this out yourself, if under must be completed by parent) Please list any significant problems you have had previously or are currently being treated for. Please include any medications you should NOT receive in emergency treatment. This information will be held in confidence and only used as necessary by authorized personnel. Minors (under 18) must also complete the Resident Student Medical Form once they accept the offer of admission. Please be aware that Chautauqua Institution cannot accommodate unique or individual dietary requirements.

IMMUNIZATION HISTORY
According to NYS Public Health Law 2164, all students must have the following immunizations: 1) One dose of measles, mumps, rubella on or after the first birthday; 2) a second dose of measlescontaining vaccine, preferable as MMR, no sooner than 1 month after the first dose and or after 15 months of age; 3) Diphtheria/tetanus booster within the past 10 years; 4) Tuberculin test for all new students (within the past 10 years). Students who are not in compliance with NY state immunization laws will not be able to reside in the residence hall. ATTENTION FOREIGN STUDENTS: In order to live in the residence hall, you must comply with the regulations of the Department of Health and Mental Hygiene concerning tuberculosis control. Every student must have a PPD test. BCG immunization does not exempt students from this requirement. If you had a BCG one year ago or more, you must have a PPD test and, if positive, you must have a chest X-ray and be placed on preventative antibiotic treatment. Students who are not compliant will be sent for a medical evaluation.
IMMUNIZATION RECORDS **Please fill in the dates below, or you may submit a copy of your immunization records from your doctors office

Td
Polio: oral (opv)/injectable (ipv)

Measles vaccine Mumps vaccine Rubella vaccine Hepatitis B Varicella (chicken pox) Meningitis Vaccine

1. 2. 3. 4. (Most recent dip/tet vaccination must be within 10 years.) 1. 2. 3. 4. 1. 2. 1. 2. 1. 2. 1. 2. 3. 1. 2. 1.

5. 5.

TB RISK ASSESMENT

PPD______ Date administered__________ Results ___________ Administered by _________

If positive, results of chest x-ray and treatment:
To induce Chautauqua Institution to accept registration and permit participation in the Chautauqua Summer Schools by the above-designated student, I hereby agree to release, indemnify and hold harmless Chautauqua Institution, its employees, contractors, directors, officers, and representatives, from any claim, loss or damage arising out of injuries to said student and/or any medical care given to said student during the period of the Chautauqua Summer Schools summer programs and transportation in connection therewith, regardless of the cause of such loss, damage or injury, whether the result of negligence or any other cause. I hereby extend permission to the authorities of the Chautauqua Institution to act on my behalf in case of an emergency, and also extend permission to the medical professional selected by the Chautauqua Institution to provide all necessary emergency medical attention, including anesthesia and surgery.

Theophilus A Chandler 03/11/2012 Student Signature _______________________________________________________ Date _________________

` Parent or Guardian Signature _____________________________________________ Date _________________ (if student is under 18)