New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and...

19
Boarding and Homestay Program 2017-2018 Return all registration and medical forms no later than August 1st to the Admissions Office by email: [email protected] or by fax: 413-467-1607 New Student Registration Packet

Transcript of New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and...

Page 1: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

6 6 S c h o o l S t r e e t

G r a n b y M a s s a c h u s e t t s

Boarding and Homestay Program

2017-2018

Return all registration and medical forms no later than August 1st to the

Admissions Office by email: [email protected] or by

fax: 413-467-1607

New Student Registration Packet

Page 2: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

Your Home and Room:

Rooms are typically doubles; however, there are some singles and triples.

You and your roommate(s) will each have your own twin size bed, chest of drawers, desk, and chair.

A laundry service, required for all Boarders, provides laundry and dry-cleaning services.

Wireless Internet is available to all students as long as the computer has been registered with our IT Department.

You must provide the following items:

Mattress cover

Pillow

2 sets of twin-size sheets and pillowcases

Blankets and bedspread or comforter

Towels

Please note: Throughout the first week of orientation, there will be several trips to the near-by mall for students to purchase items that are too heavy or big to pack.

You are allowed to use the following items in your room:

Clock radio or alarm clock

Fan, desk lamp (no halogen)

Blow dryer, curling iron, hair straightener (flat iron)

Computers – monitor may not be larger than 22 to 24 inches in diameter

American cell phone—we strongly urge that all international students have an American cell phone number.

Please Note: Space heaters, electric blankets, TVs, hot pots, etc. are not permitted and will be confiscated.

T H I N G S T O K N O W B O A R D I N G

Welcome to the MacDuffie community! As a boarding student, you will be living on campus with several peers and faculty members. Here is some information to

Page 3: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

Clothing and General Appearance:

Students are expected to be sensible in their choice of clothing and appearance.

MacDuffie guidelines are: cleanliness, neatness, and modesty. The Dress Code is detailed in the Student Handbook.

Please bring dress clothes in the event that they are needed for an evening activity such as a play or concert.

Rain gear, snow boots, and a heavy winter jacket are essential. Fall begins in mid/late Sep-tember, and students should be prepared for colder weather. These items may be purchased after arriving at school.

Personal Expenses: Students may choose to open their own bank accounts with funds for their personal use. Easthampton Savings Bank will have a representative available during the week of Orientation to assist students in opening bank accounts if they would like to do so.

Personal and Travel Documents: Within the first week of orientation, all International Students are expected to provide the Office of Boarding Life with their passports, I-20s, flight

information, and other sensitive documents that will be kept in the school’s safe.

T H I N G S T O K N O W B O A R D I N G A N D H O M E S T A Y

Boarding Student Social Permission/Overnight & Weekend

Boarding Student Travel Form

Motor Vehicle Permission Form

New Student Registration/Verification

All Medical Forms to the Nurse

Athletics Form

Boarding Forms to return (Checklist)

Homestay Forms to return (Checklist)

Form to send to current school (Not MacDuffie)

Motor Vehicle Permission Form

New Student Registration/Verification

Homestay Form

All Medical Forms to the Nurse

Athletics Form

Transcript Request Form

Page 4: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

Student’s name: ________________________________________________Grade:________

Status (circle one): 5-Day Boarding or Full-Time Boarding

Overnight and Weekend Visit Permission

Parents must give permission for Boarding Students to leave campus for any overnight visits and/or weekends.

Please circle response:

I give my child permission to go to any home for an overnight or a YES NO weekend with adult supervision at his/her discretion

In addition to this permission form, the student must have the following:

An invitation from his/her host (via e-mail)

Permission from the Dean of Boarding to leave campus Please note: In all cases your child must be under adult supervision. Boarding Students are not allowed to

stay in hotels without an adult unless we receive parent/guardian permission.

To be completed by the Parents/Guardians: Parent(s)/Guardian(s) name(s): ______________________________________________________ Date: __________________ Phone number: ___________________________________________ E-Mail: _______________________________________________________________________

Signature(s):____________________________________________________________________

To be completed by the Student: Student name: _____________________________ Date: ______________

Signature(s):___________________________________________________ International Students Only:

If the above named student has a guardian in the USA, please print his/her name, address, and telephone number.

Name:_________________________________________________________________________

Telephone:_____________________________________________________________________

Address:______________________________________________________________________

E-Mail address:__________________________________________________________________

B O A R D I N G S T U D E N T S S O C I A L P E R M I S S I O N S 2 0 1 7 - 2 0 1 8

Page 5: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

B O A R D I N G S T U D E N T S T R A V E L F O R M

All new students must arrive on Sunday, August 27, 2017. (Students must not arrive before or after the designated date).

Please note: If you are participating in the Extended Orientation Program, your arrival date will be different. We will confirm arrival date once you register for the program. To help us prepare for your arrival, please fill in the following information: Student’s name: ___________________________ _____________________________ Mobile (emergency contact): _________________________ __________________________ Email used during summer holiday: __________________ __________________________ Transportation will be provided from Bradley International Airport (BDL) only. Please provide your flight in-formation if you would like transportation provided by The MacDuffie School: Airport: Bradley International Airport (BDL) Airline: __________________________________________________ ________ _______ Flight arrival time: _________________________________________________________________________ Flight number: ______________ ________________________________________________ If you would like to arrange for private transportation, go to www.mylimo5.com and provide your infor-mation. If you have already arranged for your own private transportation, please provide the following below: Name of transportation company: __________________________________________________________________________ Contact number: __________________________________________________________________________ Campus arrival time: __________________________________________________________________________

Return to Admissions by August 1, 2017 [email protected]

Page 6: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

Student’s name:

___________________________________________________________________________

First Middle Last

Please circle your child’s status: Day/ 5-Day Boarding | Full-Time Boarding | Homestay

Grade (circle one): 6 | 7 | 8 | 9 | 10 | 11 | 12

Riding/Driving in Motor Vehicles – All Students

The MacDuffie School allows its students to ride in vehicles rented for school use and with any faculty/staff member in school vehicles or in any faculty/staff member’s private vehicle. We also permit students to ride with certain other individuals with parent/guardian approval. Please complete each of the following:

My child may ride with (circle response):

1. Any licensed driver over the age of 18 at his/her discretion: YES NO

2. Only the individuals listed below: __________________________________________________________________ __________________________________________________________________

3. Any MacDuffie student who has parent/guardian permission to drive students: YES NO

4. The parents/guardians of other MacDuffie students: YES NO

5. Any approved licensed taxi-cab driver: (No UBER or LYFT services) YES NO

Please note: The MacDuffie School does not allow students in grades 6-8 to ride alone in a taxi-cab unless they have parental permission.

Day students only: My child may drive students who have permission to ride with students: YES NO

For the Student: Name:__________________________________________________Date: _______________

Student signature:____________________________________________________________

Parent/Guardian:

Parent/Guardian name:______________________________________Date: ________________

M O T O R V E H I C L E P E R M I S S I O N

Page 7: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

N E W S T U D E N T R E G I S T R A T I O N / V E R I F I C A T I O N

S t u d e n t L e g a l

L a s t N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ F i r s t : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

M i d d l e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ N i c k n a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date of Birth: __________________________________

Gender: Male Female Grade: ______________

Student email address: ___________________________________

Student cell phone#: ______________________________

Student Lives with: Mother Father Both Parents Guardian Other _____________________________________

Father/Contact #1 Name (Last, First)

Relationship Street Number Street Name Apartment

City State Country Postal Code

Circle one: Mr./ Mrs./ Ms./Dr.

Home Phone

Cell Phone Occupation Work Phone E-mail Address

Mother/Contact #2 Name (Last, First)

Relationship Street Number Street Name Apartment

City State Country Postal Code Circle one: Mr./ Mrs./ Ms./Dr.

Home Phone

Cell Phone Occupation Work Phone E-mail Address

PLEASE BE ADVISED BY COMPLETING INFORMATION BELOW FOR AN ADDITIONAL CONTACT AND/OR A THIRD PARTY CONTACT, ALL SCHOOL COR-RESPONDENCE WILL BE SENT TO THE INDIVIDUALS LISTED. IF YOU DO NOT DO NOT WISH FOR CORRESPONDENCE TO BE SENT, DO NOT COMPLETE

THE SECTIONS BELOW.

ADDITIONAL CONTACT (IF APPLICABLE) - GUARDIAN/HOMESTAY PARENT/AGENT - WILL RECEIVE SCHOOL CORRESPONDENCE

Additional Contact Name (Last, First)

Relationship Street Number Street Name Apartment

City State Country Postal Code

Circle one: Mr./ Mrs./ Ms./Dr.

Home Phone

Cell Phone Occupation Work Phone E-mail Address

THIRD PARTY (IF APPLICABLE) - WILL RECEIVE SCHOOL CORRESPONDENCE

Third Party Name (Last, First)

Relationship Street Number Street Name Apartment

City State Country Postal Code

Circle one: Mr./ Mrs./ Ms./Dr.

Home Phone

Cell Phone Occupation Work Phone E-mail Address

Medical Emergency Contact Information: The school will attempt to contact the Parents/Guardians of a student in the event of a medical emergency. If Parents/Guardians cannot be reached, the designated Emergency Contact below will be contacted.

Name: _________________________________________Relationship to student: __________________________________

Home Phone #: ______________________________________ Cell Phone #:____________________________________ ____________________________________________________________

UPDATE YOUR RECORD THROUGHOUT THE SCHOOL YEAR WITH ANY CHANGES

Page 8: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

The MacDuffie School requires an official final transcript for all students. Please sign and send this form to your child’s FORMER SCHOOL(S).

Your child’s former school(s) must mail his or her official final transcript(s) to:

The MacDuffie School

Attn: Registrar 66 School Street

Granby, MA 01033

T R AN S C R I P T R E Q U E S T F O R M F R O M P R E V I O U S S C H O O L

Name of student: _____________________________________________________________________ First Name Middle Name Last Name I hereby authorize the release of my daughter’s/son’s official final transcript/standardized test scores to The MacDuffie School. Parent/Guardian Signature: ____________________________________Date: ___________ The student whose name appears above is enrolled at The MacDuffie School for the 2017-2018 academic year. Please send the following materials: 1. An official final transcript of the student’s grades 2. All available standardized test scores

THANK YOU FOR YOUR TIME.

Page 9: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

H O M E S TAY O N LY : S T U D E N T T R AV E L F O R M

All new Homestay Students are required to arrive at their Homestay resi-dence on Sunday, August 27, 2017. Students must not arrive before or after August 27. To help us prepare for your arrival, please fill in the following information: Please note: If you are participating in the Extended Orientation Program, your arrival date will be different. We will confirm arrival date once you register for the program. Student’s name: _________ _____ ______________________________________ Home telephone number: _____________________________________________________ Mobile (emergency contact): ______________________________________ Email used during summer holiday: ___________________________________________ Airport: Bradley International Airport (BDL) Airline: __________________________ Flight arrival time: ______________________ Flight number: __ ____________________ If you would like to arrange for private transportation go to www.mylimo5.com and provide your information below. If you have already arranged for your own private transportation, please provide the following: Name of transportation company:__________________________________________________ Contact number:______________________________________________________________ Campus arrival time:___________________________________________________________

Return to Admissions by August 1, 2017 [email protected]

Page 10: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

AT H L E T I C S C O N T R A C T

MACDUFFIE ATHLETICS PHILOSOPHY The MacDuffie School believes that a quality interscholastic athletic program is an important part of a student's educational experience. The MacDuffie Athletics Program is committed to promoting the ideals of sportsmanship, respect, commitment, integrity, reliability, and leadership. By encouraging these ideals, the goal is to build athletic ability, increase physical fitness, and help gain a sense of community. It is the mission of the program to instill in each student-athlete the basic understanding of competition – to win with class and lose with dignity. By developing comprehensive training plans, maintaining high standards, and expecting commitment by the student-athlete to the program, the coach’s priori-ty is to improve each person’s well being. Representing MacDuffie in athletics is a choice, and with choice comes the responsibility for the stu-dent-athlete to give his/her all to achieve and to excel. In addition to the physical understanding of motor skills development, the goal is also to foster the mental aspects of teamwork, ownership, cooperation, and discipline to cultivate students’ decision-making ability.

VARSITY PROGRAMS All athletes are expected to put forth their best effort whenever they are representing The MacDuffie School. The first objective is to win, but not at all costs. We strive to capture each league championship while upholding our ideals of sportsmanship, respect, commitment, and integrity. Playing time is based on performance and commitment to practice time. At the same time, whenever possible, players should be allowed play-ing time as their ability and the game situations permit. Three unexcused absences may result in removal from the team. Failure to communicate with the coach, with an acceptable reason, for missing a practice or game could result in disciplinary consequences. Varsity pro-grams at MacDuffie are a competitive experience where achievement and outcome are high priorities. Please refer to the Student Handbook or Curriculum Guide for further information on sub-Varsity teams and MacDuffie Athletics in general.

CODE OF CONDUCT FOR PLAYERS Attend all training sessions and games punctually. Notify coaching staff immediately if unable to attend.

Be honest with and pay complete attention to coaches/staff.

Maximum effort is a minimum requirement – always take pride in your performance, even at training.

Your full cooperation is always expected. Always conduct yourself with respect and behave appropriately

Learn the rules of the game.

Always take responsibility of your own belongings, uniform, and equipment, and be prepared to help out with the coaching equipment during practice/game day when asked.

Always warm up and cool down with appropriate stretching exercises before and after training and games.

Always wear the appropriate gear at practices and games.

No jewelry to be worn or mobile phones to be used during practices or games.

Do not train unless fully fit, and make sure that you report injuries as soon as they occur. Attendance will be required for injured players at both training and games at the coaches’ discretion.

Always respect other people and property – you are an ambassador for The MacDuffie School at all times.

Always work hard and be determined to do the best you can.

Playing time at varsity level is a privilege based on many factors. Your commitment to the team is expected regard-less of the situation. Failure to attend and provide 100% commitment to team events (e.g., practices, competitions, meetings, etc.) may result in a suspension from competition. The length of the suspension will be determined at the discretion of the Director of Athletics. Please refer to the Athletics Section of the Student Handbook for more infor-mation. By signing below, you are acknowledging that you agree to follow the guidelines above at all times to the best of your ability. You are also acknowledging that you must provide the school with a copy of a Physical Exam (obtained within the last 12 months) and that you have read and understand the school’s concussion policy, including the completion of the ‘ImPACT’ pre-season testing. Participa-tion in the MacDuffie School Athletics Program is dependent on you completing all of the above re-quirements.

FIRST Name: __________________________LAST Name: ___________________________

Player signature: ________________________________________ Date:__________________

Parent/Guardian signature: _________________________________ Date:_________________

Students must complete and return this form to the Athletics Office before they will be allowed to participate in athletics/sports.

Page 11: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

The following documents must be received by August 1, 2017. All infor-mation on each document must be COMPLETED, and all documents must be SIGNED:

______1. Permission to Treat Form

______2. Prescribed Medication Authorization - we supply “over-the-counter” medications for common ailments. Do NOT send any non-prescription medication with your child, as they will be confiscated upon arrival per school policy.

______3. Over-the-Counter Medication Authorization Form

______4. Massachusetts School Health Record or record of annual physical exam (must be in English language)

______5. Immunization Record -Immunization waivers may be accepted for medical or religious reason only. Please contact the nurse for the required form and approval.

______6. Immunization Consent (for boarding students only) If students have not received ALL required vaccines, students will be required to receive missing vaccinations here at school or our affiliated medical office.

______7. Annual Influenza Vaccine Consent Form

Send all health records to the Admissions Office at:

Email: [email protected]

Fax: 413-467-1607

Mail: Attn: Nurse 66 School Street Granby, MA 01033

M E D I C A L F O R M C H E C K L I S T

Page 12: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

P R E S C R I P T I O N M E D I C AT I O N A U T H O R I Z AT I O N 2 0 1 7 - 2 0 1 8

Student name: ____________________________________________________________Date of birth:___________

(LAST) (FIRST) (M/D/YY)

Dear Parents/Guardians,

Students requiring prescribed medication while at school must have a physician’s order on file at the start of each school year that includes both the phy-sician and parent/guardian signatures. Your signature below gives us permission to access all pertinent information from your child’s physician regard-ing the dispensing of medications listed below and permits authorized persons to assist the student in taking the medications listed below or to self-medicate when authorized by the physician.

________________________________________________________ ____________________

(SIGNATURE OF STUDENT AGE 18+ or PARENT/GUARDIAN) (DATE)

CHECK HERE IF NO PRESCRIBED MEDICATIONS ARE NEEDED WHILE AT SCHOOL

*Please note: This form is not required for over-the-counter medications such as Tylenol, Ibuprofen, Motrin, Benadryl, etc.

Name of medication: ______________________________________________________________________

Dose: ________________ Time of administration: __________________________Route:______________

Allergies:_______________________________________________________________________________

Diagnosis/Indications for which the medication is given: _________________________________________

Start date: _______________ Stop date:________________

Student may carry (if applicable to school protocol) and self-medicate: Yes_______ No_______

List significant side effects: _________________________________________________________________

Physician printed name and phone: ___________________________________________________________

Physician signature:___________________________________________________Date:________________

(PLEASE USE ONE FORM FOR EACH MEDICATION)

THE FOLLOWING IS TO BE COMPLETED BY THE PHYSICIAN. **All fields required

Page 13: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

Student name: ______________________________________DOB:__________

I/We, ___________________________________, the parent(s) or legal guardian(s) of the student stated above hereby authorize and request authorized The MacDuffie School personnel to administer the over-the-counter (OTC) medication(s) marked below to my student as is deemed reasonably necessary and appropriate. I agree to notify the school nurse in writing of the termination of this authori-zation or when any changes are necessary. **Before granting school permission to administer OTC medication, please check with your doctor/pharmacist that the medications below do not interact with any medications your child may already be taking. I release the school and its personnel from any and all liability should adverse reaction occur as a result of medication interaction with unknown daily medication. ________ (parent initial)

OTC medications will be given at the manufacturer’s recommended dosage for the appropriate age/weight. **Students are NOT permitted to keep OTC medications with their personal belongings.

PLEASE CHECK EACH MEDICATION FOR WHICH YOU ARE GIVING PERMISSION

_______ I approve ALL medications listed below

_______ I do NOT want ANY OTC meds given to my student

___ Acetaminophen (Tylenol) ___ Saline eye rinse &/or nasal spray

___ Ibuprofen (Motrin/Advil) ___ Cortisone cream (topical itching/rash)

___ Benadryl antihistamine (generalized allergic reaction) ___ Antibiotic cream (i.e., Bacitracin, Neosporin)

___ Antacid (i.e., Pepto Bismol, Tums) ___ Hydrocortisone cream (i.e., Cortaid)

___ Cough drops (i.e., Halls) ___ Sunscreen

___ Loperamide (anti-diarrheal) ___ Oral numbing agents (i.e., Orajel, Chloraseptic)

___ Cold medications (i.e., DayQuil, Robitussin, Mucinex) ___ Muscle rub (i.e., Icy Hot)

___ Meclizine (for nausea/dizziness, i.e., Dramamine)

___ Seasonal Allergy Medication (i.e., Claritin, Zyrtec, Flonase)

___ Constipation medication (i.e., Colace, MiraLAX)

___ Melatonin (occasional sleep aid)

___ Migraine (consists of Tylenol, aspirin, caffeine)

___ Midol (menstrual)

The school is not able to supply medication for frequent or daily use. For OTC medications not listed on this form, or if the medication must be given daily longer than 10 days, please submit the Medication Authorization Form. **This authorization expires on the last day of the school year and must be renewed at the start of each school year.

________________________________________________________ __________________

(Signature of Parent or Guardian) (Date)

O V E R - T H E C O U N T E R M E D I C A T I O N A U T H O R I Z A T I O N F O R M 2 0 1 7 - 2 0 1 8

Page 14: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

P E R M I S S I O N F O R M E D I C A L T R E A T M E N T 2 0 1 7 - 2 0 1 8

Student’s name:______________________________________ DOB: _______________ Grade: _______

I/we, _____________________________, the parent(s) or legal guardian(s) of, ______________________ a student at The MacDuffie School, authorize The MacDuffie School to give permission for medical or psychiatric treatment for the above named child at the most appropriate medical facility, in the event that I/we cannot be contacted. I/we consent to the administration of necessary and required immunizations, standing order medications, and prescription medications and consent to provide payment for all services not covered by the insurance policy.

I/we give the nurse at The MacDuffie School and the PCP, specialist, and any medical personnel that may be required two-way consent to share information that may be pertinent to my child.

Parent/Guardian name (print or type):_______________________________________________________

Parent/Guardian signature:_____________________________________________Date: _______________

**This authorization expires on June 30, 2018**

If you have NOT enrolled in the international insurance plan, please provide insurance information (including a photocopy of insurance card):

Insurance Company: _______________________________Policy Holder’s Name: __________________

Policy Holder’s Company Number: ____________________ Policy Number: _______________________

Brief Medical History: please check all that apply

Yes No

□ □ Concussion If yes, how many: ___________Date of most recent: ___________

□ □ Diabetes If yes, controlled by: _____________________________________

□ □ Asthma If yes, controlled by: _____________________________________

□ □ Seizures If yes, controlled by: _______________ Date of last: ___________

□ □ Allergies: bee sting_______; food: _______________________________;

medication: __________________________________________;

Other: ______________________________________________

□ □ On Medications (not listed above):

If yes, identify (include medication taken at home):

____________________________________________________________________________________________________________________________________________________________________________________________________________

Other medical issues: _______________________________________________________

________________________________________________________

________________________________________________________

Page 15: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

Physician’s Printed Name: _____________________________________________________________

Physician’s Signature (REQUIRED): ______________________________________ Date: ____________

VACCINE DATE GIVEN

(MM/DD/YY)

VACCINE DATE GIVEN

(MM/DD/YY)

DT/DTP/DTap (4 doses required for age 6 and under)

1

Meningococcal (1 dose required for all boarding students)

1

2 (booster recommended at age 16) 2

3 MMR (2 doses required age 1+) 1

4 2

Tdap/Td (1 dose required, age 7+) 1 Hepatitis B (3 doses required) 1

Polio (OPV/IPV) (4 doses re-quired)

1 2

2 3

3 Hepatitis A (recommended, but not required )

1

4 2

Varicella (2 doses required age 1+) 1 1

2 Human Papillomavirus (HPV) (recommended, but not required)

1

History of varicella disease, please write date of disease

2

BCG (not required) 1 3

Tuberculin (PPD test) required yearly for international and high risk students.

1 Influenza (recommended, but not required) - Last date given

1

***If PDD is positive, chest x-ray is required. Record results here

I M M U N I Z AT I O N R E C O R D

Page 16: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

(Students MUST receive all Massachusetts state required immunizations to attend school)

STUDENT NAME:________________________________________________________ DOB(m/d/y):______________

***FOR BOARDING STUDENTS ONLY***

I/we, ______________________________________ agree that The MacDuffie

School nursing staff, or affiliate medical office, have permission to administer any missing

state required vaccine to the child listed above. Any student UNDER the age of 19 will re-

ceive required vaccines under the Massachusetts Vaccine Program free of charge. I/we

(listed above) also agree that any student OVER the age of 19 will accept the responsibility

of payment of any missing required vaccine not covered by their health insurance policy.

Parent signature: _________________________________________________

Date (DD/MM/YY): _______________________________________________

____ I do not agree due to religious beliefs or medical exemption. (Please contact the

nurse for documentation that will need to be provided to the school at

[email protected])

VA C C I N E C O N S E N T F O R M 2 0 1 7 - 2 0 1 8

Page 17: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

ANNUAL INFLUENZA VACCINE CONSENT FORM 2017-2018

____________________________________ _________________

Student name Date of birth (M/D/Y)

Screening for Vaccine Eligibility

The following questions will help us to know if your child can get the seasonal influenza vaccine. If you answer “NO” to all four of the following questions, your child can probably get the influenza vaccine. If you answer “YES” to one or more of the following four questions, your child may be able to get the seasonal influenza vaccine, but we will contact you to discuss your options.

Please mark YES or NO for each question.

Consent

CONSENT FOR CHILD’S VACCINATION:

I have read or had explained to me updated Vaccine Information Statement (VIS) for the seasonal influenza vaccine and understand the risks and benefits. To review the VIS you can visit: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html

________ I GIVE CONSENT to the MacDuffie School and its staff for my child, named at the top of this form, to be vaccinated with this vaccine. (If this consent form is not signed, then your child will not be vaccinated)

________ I DO NOT GIVE CONSENT to the MacDuffie School and its staff for my child, named at the top of this form, to be vaccinated with this vaccine.

Printed name of Parent/Legal Guardian _____________________________________

Signature of Parent/Legal Guardian ____________________________________________

Date: month_________day_________year___________

Day Student ________ Homestay Student __________ Boarding Student_________

YES NO

1. Does your child have a serious allergy to eggs?

2. Does your child have any other serious allergies? Please list:

_________________________________________________

3. Has your child ever had a serious reaction to a previous dose of flu vaccine?

4. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe

muscle weakness) within 6 weeks after receiving a flu vaccine?

Page 18: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there
Page 19: New Student Registration Packet · 2 sets of twin-size sheets and pillowcases Blankets and bedspread or comforter Towels Please note: Throughout the first week of orientation, there

MacDuffie School Vacation Dates 2017-2018

Parents, guardians, and students should avoid making any arrangements which conflict with these dates. It is very im-

portant that all students attend classes on all school days, and be present at Commencement. Arrangements which ex-

tend vacation periods by either beginning them early or ending them late must be avoided. Each and every class day at

MacDuffie is extremely valuable in the academic lives of our students.

Thanksgiving Break

Last day of classes is Tuesday, November 21, 2017

Boarding students: depart Wednesday, November 22, 2017 by 12:00 noon.

Boarding students must return by 8:00 p.m. Sunday, November 26, 2017

All Students: Classes resume at 8:00 a.m. Monday, November 27, 2017

December Vacation

Last day of exams is Tuesday, December 19, 2017

Boarding students: depart Wednesday, December 20, 2017 by 6:00 p.m.

Boarding students must return by 8:00 p.m. Wednesday, January 3, 2018

All Students: Classes resume at 8:00 a.m. on Thursday, January 4, 2018

March Vacation

Last day of classes is Friday, March 9, 2018

Boarding students: depart Saturday, March 10, 2018 by 6:00 p.m.

Boarding students must return by 8:00 p.m. Sunday, March 25, 2018

All Students: Classes resume at 8:00 a.m. Monday, March 26, 2018

Summer Vacation

Commencement is Saturday, June 9, 2018

All students are required to attend Commencement

Boarding students: depart Sunday, June 10, 2018 by 6:00 p.m.

The school will provide transportation to boarding students only on departure/arrival days. Locations are only to/from Bradley International Airport (BDL) in Hartford, CT, the Amherst Center Bus Stop, and the Amtrak Train Station in Springfield, MA.

Boarding Students are not permitted to stay on campus during Thanksgiving, December, March

and Summer vacations. The school and campus are closed during these school vacations.