Welcome to 2011!!

Transcription

1 Welcome to 2011!! This registration packet contains three sections. Please make sure all are complete before sending them back. This must be completed and received by June 17 for full enrollment. Section 1 Medical Form Part One: Attach official immunization record Part Two: Medical consent signed by parent Part Three: TB screening signed by medical provider Part Four: Meningitis Vaccination/Waiver Section 2 Waivers Part One: Medical Waiver Part Two: Legal Waiver Section 3 Policies Part One: Prescription Policy Part Two: Expectations Policy Thank you for your interest in the Strings@Smith Summer Program. If you have any further questions, please strings@smith.edu We look forward to meeting you and your student this summer! Page 1

2 Section 1 Part One: OFFICIAL IMMUNIZATION RECORD Please attach a copy of your child s official immunization record. Part Two: PARENTAL CONSENT TO TREATMENT We/I understand that our/my son/daughter,, has been selected to attend the Strings at Smith Program, to be held July 17-22, 2011, on the campus of Smith College, Northampton, Massachusetts. We do hereby request that the Strings at Smith Program take whatever steps necessary to secure medical treatment of our/my child named above in the event s/he appears to be in need of such treatment while attending the Strings at Smith Program. We consent to the rendering of all necessary treatment, including admission to a hospital or another appropriate health care facility, in such institutions and at such places as the Strings at Smith Program, acting through its agents, deems best. We/I authorize the agents or employees of the Strings at Smith Program to execute whatever forms might be necessary to ensure complete and adequate care of my/our child. Signature of student Date Signature of legally responsible parent or guardian Date Page 2

3 Part Three: TUBERCULOSIS SCREENING Name Last First Middle Date of Birth Risk Assessment Questionnaire Yes No A. To the best of your knowledge, have you ever had close contact with anyone who was sick with tuberculosis? B. Were you born in one of the countries listed below? C. Have you traveled or lived for more than one month in any of the countries listed below COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB)* *World Health Organization Global tuberculosis control. WHO report Afghanistan Djibouti Latvia Philipines Algeria Dominican Republic Lesotho Romania Angola Ecuador Liberia Russian Federation Armenia El Salvador Lithuania Rwanda Azerbaijan Equatorial Guinea Madagascar SaoTome & Principe Bahrain Eritea Malawi Senegal Bangladesh Estonia Malaysia Sierra Leone Belarus Ethiopia Maldives Solomon Islands Benin Gabon Mali Somalia Bhutan Gambia Marshall Islands South Africa Bolivia Georgia Mauritania Sri Lanka Bosnia & Herzegovina Ghana Mauritius Sudan Botswana Guam Micronesia Suriname Brazil Guatemala Moldova, Republic Swaziland Brunei Darussalam Guinea Mongolia Syrian Arab Republic Durkina Faso Guinea-Bissau Morocco Tajikistan Burundi Guyana Mozambique Tanzania, UR Cambodia Haiti Myanmar Thailand Cameroon Honduras Namibia Togo Cape Verde India Nepal Tokelau Central African Republic Indonesia New Caledonia Turkmenistan Chad Iran Nicaragua Uganda China Iraq Niger Ukraine China, Hong Kong SAR Kazakhstan Nigeria Uzbekistan China, Macao SAR Kenya Northern Mariana Islands Vanuatu Comoros Kiribati Pakistan Vietnam Congo Korea, DPR Palau Yemen Congo, DR Korea, Republic Papua New Guinea Zambia Cote d Ivoire Kyrgyzstan Paraguay Zimbabwe Croatia Lao, PDR Peru If the answers to the above questions are all NO, have your doctor review and sign the form. No further action is needed. If the answer to ANY of the above questions is YES, you are required to have a Tuberculin Skin Test (See attached.) If you had a positive PPD in the past and you were not treated for latent or active TB, you do not need a PPD, but you are required to have a chest x-ray within the last 12 months. Student Signature Date Provider Signature (verify above) Date Page 3

4 Medical Evaluation of College and University Students for Latent Tuberculosis Infection (If the answer to any of the questions on the Risk Assessment was yes you are required to complete this page.) Name Last First Middle Date of Birth TUBERCULIN SKIN TEST Date of testing Date of result Result (48-72 hours) mm of duration in horizontal diameter. (If no induration, mark 0 ) Note: Use 5 TU Mantoux test (Intermediate PPD) only; result of multiple puncture tests, such as Tine, Heaf, or Mono-vacc, not accepted. If unavailable, please defer testing until you arrive at Smith College. Interpretation of Tuberculin Skin Test RISK FACTOR POSITIVE RESULT Close contact with a case of tuberculosis 5 mm or more Born in a country that has a high rate of tuberculosis Traveled or lived for one month or more in a country that has a high rate of tuberculosis 10 mm or more 10 mm or more None (test not recommended) 15 mm or more Risk-based interpretation NEGATIVE POSITIVE (If positive, chest x-ray prior to enrollment is required see below) Chest X-ray and treatment Chest x-ray (For newly positive PPD, a current chest x-ray is required; if PPD positive in the past but not treated for active or latent TB, a chest x-ray within the last 12 months prior to enrollment is required.) DATE of chest x-ray: NORMAL ABNORMAL Treatment (required for active tuberculosis, recommended for latent tuberculosis infections) YES DRUG, DOSE, FREQUENCY, AND DATES NO PROVIDER SIGNATURE DATE Page 4

5 Part Four: MENINGITIS WAIVER/VACCINE Information about Meningococcal Disease and Vaccination and Waiver for Students at Residential Schools and Colleges Revised legislation in Massachusetts now requires all newly enrolled full-time students attending a secondary school (e. g., boarding schools) or postsecondary institution (e.g., colleges) who will be living in a dormitory or other congregate housing licensed or approved by the secondary school or institution to: 1. receive meningococcal vaccine; or 2. fall within one of the exemptions in the law, which are discussed on the reverse side of this sheet. The law provides an exemption for students signing a waiver that reviews the dangers of meningococcal disease and indicates that the vaccination has been declined. To qualify for this exemption, you are required to review the information below and sign the waiver at the end of this document. Please note, if a student is under 18 years of age, a parent or legal guardian must be given a copy of this document and must sign the waiver. What is meningococcal disease? Meningococcal disease is caused by infection with bacteria called Neisseria meningitidis. These bacteria can infect the tissue that surrounds the brain and spinal cord called the meninges and cause meningitis, or they can infect the blood or other body organs. In the US, about 1,000-3,000 people get meningococcal disease each year and 10-15% die despite receiving antibiotic treatment. Of those who live, another 11-19% lose their arms or legs, become deaf, have problems with their nervous systems, become mentally retarded, or suffer seizures or strokes. How is meningococcal disease spread? These bacteria are passed from person-to-person through saliva (spit). You must be in close contact with an infected person s saliva in order for the bacteria to spread. Close contact includes activities such as kissing, sharing water bottles, sharing eating/drinking utensils or sharing cigarettes with someone who is infected; or being within 3-6 feet of someone who is infected and is coughing or sneezing. Who is at most risk for getting meningococcal disease? People who travel to certain parts of the world where the disease is very common are at risk, as are military recruits who live in close quarters. Children and adults with damaged or removed spleens or an inherited disorder called terminal complement component deficiency are at higher risk. People who live in settings such as college dormitories are also at greater risk of infection. Are some students in college and secondary schools at risk for meningococcal disease? College freshmen living in residence halls or dormitories are at an increased risk for meningococcal disease as compared to individuals of the same age not attending college. The setting, combined with risk behaviors (such as alcohol consumption, exposure to cigarette smoke, sharing food or beverages, and activities involving the exchange of saliva), may be what puts college students at a greater risk for infection. There is insufficient information about whether new students in other congregate living situations (e.g., residential schools) may also be at increased risk for meningococcal disease. But, the similarity in their environments and some behaviors may increase their risk. The risk of meningococcal disease for other college students, in particular older students and students who do not live in congregate housing, is not increased. However, meningococcal vaccine is a safe and efficacious way to reduce their risk of contracting this disease. Is there a vaccine against meningococcal disease? Yes, there are currently 2 vaccines available that protect against 4 of the most common of the 13 serogroups (subgroups) of N. meningitidis that cause serious disease. Meningococcal polysaccharide vaccine is approved for use in those 2 years of age and older and meningococcal conjugate vaccine is approved for use in those 2-55 years of age. Both of the vaccines provide protection against four serogroups of the bacteria, called groups A, C, Y and W-135. These four serogroups account for approximately two-thirds of the cases that occur in the U.S. each year. Most of the remaining onethird of the cases are caused by serogroup B, which is not contained in either vaccine. Protection with the meningococcal polysaccharide vaccine is not lifelong; it lasts about 3 to 5 years in healthy adults (some people may be protected longer.) The meningococcal conjugate vaccine is expected to help decrease disease transmission and provide more long-term protection. Page 5

6 Is the meningococcal vaccine safe? A vaccine, like any medicine, is capable of causing serious problems such as severe allergic reactions. Getting meningococcal vaccine is much safer than getting the disease. Some people who get meningococcal vaccine have mild side effects, such as redness or pain where the shot was given. These symptoms usually last for 1-2 days. A small percentage of people who receive the vaccine develop a fever. The vaccine can be given to pregnant women A few cases of Guillain-Barre syndrome (GBS), a rare but serious nervous system disorder, have been reported among people who received meningococcal conjugate vaccine. This information is still being evaluated by health officials. An ongoing risk of serious meningococcal disease exists. At this time, experts continue to recommend vaccination for those at increased risk of acquiring meningococcal disease. However, persons who have had GBS should generally not receive meningococcal conjugate vaccine, and should talk to their doctor about their other options for vaccination Is it mandatory for students to receive meningococcal vaccine for entry into secondary schools or colleges that provide or license housing? Massachusetts law (MGL Ch. 76, s.15d) requires newly enrolled full-time students attending a secondary school (those schools with grades 9-12) or postsecondary institution (e.g., colleges) who will be living in a dormitory or other congregate housing licensed or approved by the secondary school or institution to receive meningococcal vaccine. At affected secondary schools, the requirements apply to all new full-time residential students, regardless of grade (including grades pre-k through 8) and year of study. All students covered by the regulations must provide documentation of having received a dose of meningococcal polysaccharide vaccine within the last 5 years (or a dose of meningococcal conjugate vaccine at any time in the past), unless they qualify for one of the exemptions allowed by the law. Whenever possible, immunizations should be obtained prior to enrollment or registration. However, students may be enrolled or registered provided that the required immunizations are obtained within 30 days of registration Students may begin classes without a certificate of immunization against meningococcal disease if: 1) the student has a letter from a physician stating that there is a medical reason why he/she can t receive the vaccine; 2) the student (or the student s parent or legal guardian, if the student is a minor) presents a statement in writing that such vaccination is against his/her sincere religious belief; or 3) the student (or the student s parent or legal guardian, if the student is a minor) signs the waiver below stating that the student has received information about the dangers of meningococcal disease, reviewed the information provided elected to decline the vaccine. Where can I get more information? Your healthcare provider The Massachusetts Department of Public Health, Division of Epidemiology and Immunization at (617) or and Your local health department (listed in the phone book under government) Waiver for Meningococcal Vaccination Requirement I have received and reviewed the information provided on the risks of meningococcal disease and the risks and benefits of meningococcal vaccine. I understand that Massachusetts law requires newly enrolled full-time students at secondary schools, colleges and universities who are living in a dormitory or congregate living arrangement licensed or approved by the secondary school or postsecondary institution to receive meningococcal vaccinations, unless the students provide a signed waiver of the vaccination or otherwise qualify for one of the exemptions specified in the law. After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of meningococcal vaccine. Student Name: Date of Birth: Student ID or SSN: Signature: Date: (Student or parent/legal guardian, if student is under 18 years of age) Provided by: Massachusetts Department of Public Health / Division of Epidemiology and Immunization / MDPH Meningococcal Information and Waiver Fom September 2008 Page 6

7 Section 2 Part One: MEDICAL WAIVER Smith College Summer Programs Medical Information and Release (Waiver) Form for Parents This information will be kept by the Summer Program Director and the Health Insurance Provider. The Director or Health Insurer may share the information as they deem necessary with health care providers or insurance carriers. The information is required for attendance in any Smith Summer Program in order that the participant may be provided with emergency medical coverage for accidents or illness arising in the course of the program. Student Last Name Student First Name Date of Birth Social Security Number Home Phone Number Student Cell Phone Person to be notified in case of a medical emergency Parent/Guardian Name Alternate Person to be contacted in case of a medical emergency Parent Cell Phone Number 1 Parent/Guardian Name Parent Cell Phone Number 2 Non-Parent Emergency Contact Name Non-Parent Cell Phone Number Medical Release: If medical treatment is necessary, I hereby authorize any physician or trainer selected by Summer Program personnel to order and conduct medical procedures for my child (above-named Participant) as necessary. I have indicated all health concerns or medical conditions that could adversely impact or limit my child s participation in the program (e.g., asthma) or emergency treatment below,including drug, food or environmental allergies, (e.g., bee stings). Parent Signature <Field Missing> I affirm that I am authorized to sign on behalf of my child s other parent, or that I have sole custody of my child Medical Information <Field Missing> Page 7

8 Part Two: LEGAL WAIVER Smith College Summer Programs Assumption of Risk / Release & Indemnification of All Claims / Covenant Not to Sue This is a legal and binding agreement which, when signed, will permanently limit your ability to recover from the parties indicated below for injuries or losses you may sustain as a result of Smith College Summer Program participation. The Trustees of Smith College is a non-profit educational institution. References to Smith College include The Trustees of Smith College, its trustees, employees, volunteer workers, students, participating organizations, agents, assigns, and participants in the Summer Program activities described below. I (PARTICIPANT) freely choose to participate in the Strings@Smith Summer Program and related activities (henceforth referred to as the Program) at Smith College, from July 17, 2010, to July 22, I (PARENT) freely permit my child to participate in the Strings@Smith Summer Program and related activities (henceforth referred to as the Program) at Smith College, from July 17, 2010, to July 22, I understand that Smith College is not an agent of, and has no responsibility for, any third party including without limitation any sponsor which may provide any services including food, lodging, travel, or any equipment associated with the Program. Participating in any activity is an acceptance of some risk of injury. I (Participant) agree that my safety is primarily dependent upon my taking proper care of myself. I understand that it is my responsibility to know what personal equipment is required and provide the proper personal equipment for my participation in the Program, and to ensure that it is in good and suitable condition. I agree to ask questions to make sure that I know how to safely participate in the activity, and I agree to observe the rules and practices that may be employed to minimize the risk of injury while pursuing the benefits of the activity. I agree to advise the Program Director or her designee immediately if I do not believe I can safely continue in the activity. For any recreational activities, I agree to reduce the risk of injury to myself and/or others by only participating at my personal fitness level, wearing the proper protection as dictated by the activity, not wearing anything that would pose a hazard in the activity, and not ingesting or using any substance at any time that could pose a hazard to myself or others. I agree that if I fail to act in accordance with this agreement I may be required to leave the program and forfeit any fees. I (Parent) agree to my child s responsibility for her actions and these conditions. Despite precautions, accidents and injuries can occur. I understand that travel and other recreational activities the Program may undertake may be potentially dangerous, and that I may be injured and/or lose or damage personal property or suffer financial loss as a result of participation in the Program. Therefore I (Participant and Parent) ASSUME ALL RISKS RELATED TO THE ACTIVITIES including but not limited to: X Death, drowning, injury or illness from accidents of any nature whatsoever, including but not limited to bodily injury, head, facial, oral or eye injury or trauma, mental injury, joint trauma, broken bones, other muscular-skeletal injury, or illness, of any nature whether severe or not, temporary or permanent which may occur as a result of participating in an activity or contact with physical surroundings, equipment or other persons or arising from travel or food poisoning arising from the provision of food or beverage by individuals, restaurants or other service providers. X Loss or injury as a result of a crime or criminal act by third parties, terrorism, war, civil unrest, riot, detention by a foreign government, arrest or other act of any government or authority X Theft or loss of personal property during the Program or any Program related travel X Loss or death or injury as a result of any natural disaster or event or extreme weather conditions or events X Alteration including delay, extension or cancellation of the Program due to natural disaster, civil unrest, war, terrorist attack, medical quarantine or any other disturbances or causes. I further acknowledge that the above list is not inclusive of all possible risks associated with the Program or the use of facilities, equipment, or services in association with the Program, and that the above list in no way limits the extent or reach of this release and covenant not to sue. I further understand that participating in this Program is an acceptance of risk of injury. Strings@Smith 2011 Registration I (Participant and Parent) authorize Smith College to act on my behalf in the event of a medical emergency. Release from Liability, Indemnification Agreement and Covenant Not to Sue In consideration of my participation in the Program, I the undersigned Participant and Parent, to the fullest extent permitted by law, agree to forever release and on behalf of myself, my spouse, child, heirs, representatives, executors, administrators and assigns, HEREBY DO FOREVER RELEASE Smith College from any cause of action, claims, or demands of any nature whatsoever, including but not limited to a claim of negligence which I or my/my child s spouse, heirs, representatives, executors, administrators and assigns may now have, or have in the future against Smith College on account of personal injury, bodily injury, property damage, death or accident of any kind, arising out of or in any way related to my /my child s participation in the Program and/or the use of facilities, equipment, or services in association with the Program howsoever the injury is caused, whether by the negligence of Smith College or otherwise. In consideration of my participation in the Program I, the undersigned Participant and Parent, COVENANT NOT TO SUE and agree to INDEMNIFY AND HOLD HARMLESS Smith College from any and all causes of action, claims, demands, losses or costs of any nature whatsoever arising out of or in any way relating to my/my child s participation in the Program and my/my child s use of facilities, equipment, or services in association with the Program. I hereby certify that I have full knowledge of the nature and extent of the risks inherent in the Program and the use of facilities, equipment, or services in association with Program, and that I am voluntarily assuming all risks, whether known or unknown. I (Participant and Parent) understand that I will be solely responsible for any loss or damage, including death, which I sustain or cause, whether in whole or in part, while participating in the Program and my/my child s use of facilities, equipment, or services in association with the Program, and that by this agreement I am relieving Smith College of any and all liability for such loss, damage or death. My signature below indicates and certifies that I (Participant and Parent) have carefully read, understood and freely signed this agreement, which shall take effect as a sealed instrument, of my own free will. I further certify that I (Parent) am legally competent to sign this agreement. I (Participant and Parent) further understand that the terms of this agreement are legally binding. This agreement is made in sole consideration of Smith College permitting my/my child s participation in the Program and my/my child s use of facilities, equipment, or services associated with the Program. This agreement shall be construed and enforced in accordance with the laws of the Commonwealth of Massachusetts, and I (Participant and Parent) consent to the jurisdiction of said state. I expressly agree that this waiver and release is intended to be as broad and inclusive as permitted under the laws of the Commonwealth of Massachusetts, that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. IN WITNESS WHEREOF, this instrument is duly executed at, this day of, 20. IMPORTANT - READ ENTIRE AGREEMENT BEFORE PLAYING Participant Signature: Date: day/month/year Name Printed: Parent Signature: Date: (day/month/year) Parent Name Printed: Page 8

9 Section 3 Part One: PRESCRIPTION POLICY Prescription Policy The Strings at Smith Summer Program (SSSP) policy on dispensing prescription medicine for participants is stated below. Participants who take prescription medication will receive their scheduled prescription from a registered nurse employed by the program who will dispense and record each dose. Please discuss this policy with your son or daughter to ensure that he or she understands it fully, and then sign one copy and return it to us in the enclosed stamped envelope. Your signatures will verify that you have read and understand the terms of this policy. Participant Name: 1. All prescription medications must be maintained in their original containers and be clearly labeled upon a participant's arrival and throughout the Strings at Smith Summer Program. 2. Prescription medications will be kept locked in an area designated by the program director and will be accessible to the Program s Nurse for distribution. Exceptions may be made for medications needed for asthma, allergies, acne, as well as others and should be discussed with program director and nurse at participants arrival. 3. Daily dosages of prescription medications that are given out by the Program s Nurse will be administered to participants each weekday at a time to be determined by the Nurse. This will be communicated to all parents and participants upon arrival. It is a participant's responsibility to arrive at the Nurse s office in a timely fashion to receive his/her medications. If a participant does not comply with the schedule for receiving prescription medication, the SSSP Residential Director will make every attempt to inform parents promptly. Repeated refusals to comply with the schedule for receiving prescription medications will result in the expulsion of the participant. 4. When appropriate, participants will take their prescription medication witnessed by the nurse or aid. Otherwise, a daily or weekend dose will be given to the participant in an appropriately marked container that then must be kept on the participant's person. 5. Under no circumstances may a participant knowingly share her medications with any one else, or knowingly take another participant's medication. In the event that a participant has reason to believe that someone other than herself has had access to his/her medication, s/he must notify the Residential Director immediately. If a participant should require additional prescription medications in the course of medical care provided by licensed medical professionals during the 2011 SSSP, every attempt will be made to notify parents promptly by phone, and a dated written record of such will be maintained by the Residential Director. We agree in full to the terms of the Policy as stated above. Parent Signature(s), Date Participant Signature, Date Permission is given for the following over the counter medications: All over the counter medications will be kept locked in an area designated by the program director and may be accessed and distributed by either the program nurse, program director, or by a staff member appointed by the program director. Tylenol Yes No Ibuprofen Yes No Benadryl (for suspected allergic reactions) Yes No Caladryl/or any other OTC anti itch cream Yes No Parent/Guardian Signature(s), Date Page 9

10 Part Two: EXPECTATIONS POLICY Expectations policy & contract 2011 Registration Please read the Expectations Policy & Contract, which includes both the Behavior Contract and the College Property Policy at and complete the following: I have read the Expectations Policy & Contract including both the Behavior Contract and the College Property Policy at and I hereby agree to the conditions of participation outlined there. Smith College has/does not have (circle one) my permission to use my child s photograph, video and audio recordings, likeness, and comments in publications, web pages and other promotional materials produced, used by and representing Smith College for the purpose of promoting Strings@Smith. I understand the circulation of the materials could be worldwide and that there will be no compensation to me for this use. Student Signature: Date: Parent/Guardian Signature: Date: Print Student Name: Page 10