Order now and save! $920 after 8/15/12 - Suffield Academy

Suffield Academy 

Registration Packet Return Checklist for NEW DAY STUDENTS 

Forms required for students due by July 15, 2012 

Database Verification Sheet 

Acknowledgement of Suffield Academy 

Medical Philosophy 

Physical Examination Record for New 

Students 

Immunization History for New Students 

Permission for Medical or Surgical 

Treatment for All Students 

Permission to Administer Influenza 

Vaccine 

Suffield Academy Concussion 

Testing 

Student Health Insurance 

Waiver/Enrollment 

Copy of Health Insurance Card 

(front and back) 

Student Debit Card Form 

Photo Permissions & Press 

Release Form 

Additional forms, if applicable. 

Administration of Prescription Medicine 

by School Personnel Authorization. 

Music Lesson Registration 

Laundry/Dry Cleaning Service

[ 

[ 

suffield academy 

[ Suffield, Connecticut / 860.386.4400 

2012/13 student forms 

ID# 

date of birth 

CONSENT TO USE OF ELECTRONIC SIGNATURES PROGRAM 

To the Parent(s) or Legal Guardians of Students at Suffield Academy, classes of 2013, 2014, 2015 and 2016: 

As of June 1, 2012, Suffield Academy (“Suffield”) will begin implementing an Electronic Signature Program for the 2012-2013 academic year and beyond. 

Under this system, parents and legal guardians of Suffield students sign certain forms by completeing them electronically during the course of their child’s time 

at Suffield Academy. These forms will be electronically retained by Suffield. 

Participation in the Electronic Signature Program is optional. 

To participate in the Electronic Signature Program, please read the following information carefully. If you have any questions regarding 

the Electronic Signature Program, please contact Patrick Booth, Chief Financial Officer at pbooth@suffieldacademy.org. 

Electronic Signature Program: Parent Information 

Participation is optional. Suffield’s Electronic Signature Program is designed to be an optional convenience for parents. You are not required to participate. 

A decision not to participate does not affect your rights regarding disclosure of school records or your access to those records. You can simply print out the 

attached forms and send them back to Suffield Academy, 185 North Main Street, Suffield, Connecticut 06078. However, we strongly urge you to consider the 

benefits of an electronic signature, including better data accuracy, and a more green approach to paper management. 

You may withdraw your consent at any time. If you choose to participate in the Electronic Signature Program now, but change your mind later, you 

may withdraw your consent. Doing so will not result in the assessment of any fees. Please bear in mind that withdrawing your consent will not invalidate any 

documents you have previously signed electronically. 

To withdraw your consent, you may print out and sign a “Withdrawal of Consent to Use of Electronic Signature” form, which is located in the Parent Portal of 

the Suffield Academy website on the Forms & Documents page (login required). Return the form to the Suffield Academy Business Office via mail or fax. 

You may obtain a paper copy of any document you sign electronically. If at any time you wish to receive a paper copy of any document that you 

have signed electronically, please call or email Kim Goodwin 860-386-4400 or kgoodwin@suffieldacademy.org with your request. 

Your consent applies only to certain documents. Your consent to participate in the Electronic Signature Program applies only to online forms 

(e.g. emergency medical treatment, field trip approval, re-enrollment contracts, plus others as they become necessary.) 

You must inform Suffield Academy of any changes in your email address. To effectively participate in the Electronic Signature Program, you 

must agree to inform Suffield Academy promptly of any changes in your email address. 

Consent to Electronic Signatures and Documents: By completing and emailing this consent form to Kim Goodwin, kgoodwin@suffieldacademy.org 

you are providing electronic consent to the use of electronic documents and signatures during your child’s Suffield Academy enrollment. 

Specifically, you are acknowledging receipt of this form and consenting to the use of electronic documents, email delivery of documents, and electronic 

signatures in any transactions involving you, your child, and their academic experience at Suffield Academy, including boarding and all extracurricular activities. 

By checking this box you agree that the addition of your child’s student ID in the top right 

hand corner of all forms acts as an electronic signature on all Suffield Academy forms. 

Parent or Guardian Name (please print and sign here if you intend to use a printed copy of this form) 

date 

[ 

FORM: SIGNATURE / DUE: 07.15.12


Suffield, Connecticut / 860.386.4400 

2012-2013 ACADEMIC CALENDAR 

September 

Tuesday 4 Varsity Candidates Registration (by invitation) – 10:00 A.M.-12:00 

Thursday 6 New International Students Registration – 9:30-11:00 A.M. 

Thursday 6 Remaining Seniors Registration – 9:30-11:00 A.M. 

Friday 7 Remaining Grades 9, 10, 11 Students Registration – 1:00-3:30 P.M. 

Monday 10 Convocation; classes begin 

October 

Friday-Saturday 12-13 Fall Parents’ Weekend 

Saturday 13 Extended Weekend begins – 5:00 P.M. 

Tuesday 16 Extended Weekend ends – 7:30 P.M. 

Wednesday 17 Classes resume 

November 

Monday-Friday 12-16 Fall Term Examinations 

Friday 16 Thanksgiving Recess begins – 12 NOON 

Monday 26 Thanksgiving Recess ends – 7:30 P.M. 

Tuesday 27 Classes resume 

December 

Wednesday 19 Winter Vacation begins – 12:05 P.M. 

January 

Sunday 6 Winter Vacation ends – 7:30 P.M. 

Monday 7 Classes resume 

Thursday 31 Extended Weekend begins – 12:05 P.M. 

February 

Monday 4 Extended Weekend ends – 7:30 P.M. 

Tuesday 5 Classes resume 

March 

Friday 1 Spring Vacation begins – 12:05 P.M. 

Sunday 24 Spring Vacation ends – 7:30 P.M. 

Monday 25 Classes Resume 

April 

May 

Friday-Saturday 26 Spring Parents’ Weekend (Parents’ Association Auction on Friday) 

Saturday 27 Extended Weekend begins – 5:00 P.M. 

Monday 29 Extended Weekend ends – 7:30 P.M. 

Tuesday 30 Classes Resume 

Thursday 23 Reception for Seniors and Parents followed by Dinner – 5:15 P.M. 

Thursday 23 Baccalaureate – 8:00 P.M. 

Friday 24 180th Commencement – 10:30 A.M. 

Sunday-Thursday 26-30 Spring Term Examinations for Grades 9-11 

Thursday 30 Close of School for Grades 9-11 – 12 NOON



Dress Code Guidelines 

As published in the 2011-2012 Student & Parent Handbook* 

Suffield Academy’s dress code provides an essential element of a foundation for success. Students who enroll at Suffield should do so with the expectation that 

they will be asked to abide by the letter and the spirit of Suffield’s dress code. The letter of the dress code is embodied in the guidelines below. 

The intent of the dress code is to encourage appropriateness of dress for both boys and girls. Students should keep themselves clean and neat, and clothing 

should be in good repair. One key element of appropriateness is modesty in dress that is neither in bad taste nor distracting or revealing. 

Note: Boys’ and girls’ formal dress applies to clothing worn during the class day (Monday through Saturday) and within the academic buildings/quadrangle 

(south of Stiles Lane and west of Main Street). 

Boys’ Formal Dress 

• A sport jacket with buttons (no zippers) and a formal lapel (not collar) must be worn at all times, except during the month of September. 

• A tucked-in dress shirt and tie, a non-zippered turtleneck shirt/sweater, or mock turtleneck in good repair. 

• Dress slacks, corduroys or chinos with hidden tailored pockets and no frayed bottoms; a belt is required for boys. 

• Dress shoes and socks. 

Girls’ Formal Dress 

• A dress, which must extend to the knee. Dresses without sleeves must be accompanied by a sweater; footwear must be either dress shoes or styled sandals. 

• A dress skirt, which must extend to the knee, with a buttoned, woman’s blouse or woman’s dress shirt; or turtleneck shirt/sweater; footwear must be either 

dress shoes or styled sandals. 

• Dress slacks, corduroys, or chinos with hidden tailored pockets and no frayed bottoms accompanied by a woman’s blouse or woman’s dress shirt or 

turtleneck shirt/sweater. 

Note: A dress shirt does not include rugby shirts, tank tops, short or long-sleeved polo shirts, flannel shirts, or any shirt with writing. 

Shoes that attach only between the toes are not permitted. 

Saturday Morning Dress Code 

Students may choose between formal dress code and Suffield Spirit dress code from 8:00-11:15 A.M. on Saturday mornings, except when otherwise stipulated. 

Suffield Spirit Dress includes the following—visible Suffield regalia (athletic jersey or Suffield Academy clothing from the school’s bookstore) above the waist in 

conjunction with formal dress for boys and girls. The intent of this dress code option is to encourage school spirit. 

*Dress code is subject to change. Please refer to the 2012-13 Student & Parent Handbook when it becomes available in July 2012.



STUDENT DEBIT ACCOUNT INFORMATION [page 1 of 3] 

All student charges and purchases other than tuition are made through the Suffield Academy Debit Card System. The Suffield Academy Debit Card is similar to a 

standard bank ATM card. While cash and checks are universally accepted for purchases and school charges, credit cards (Visa and MasterCard) are accepted in 

the Suffield Academy Bookstore. 

The Suffield Academy Debit Card is the preferred medium of exchange for student purchases at the School. Similar to an ATM card, purchases and withdrawals 

can only be made as long as there is a sufficient balance in the account to cover the transaction. Each student is required to have a Suffield Academy Debit Card 

for school expenses and to present it at the time of a transaction. The card also serves as the student’s official photo ID card. There is a charge of $25 to replace a 

lost Debit Card. Your child’s Debit Card will be valid throughout his or her years at Suffield Academy. The card is required for all student purchases 

and withdrawals. 

Experience has shown that, with this system, students view the money in their account as their own and, for the most part, they demonstrate greater fiscal 

responsibility throughout the year than with open-ended charge privileges. This system will provide our students a valuable and realistic experience in handling 

money and will provide parents and guardians greater control over their child’s miscellaneous spending. 

The reverse side of this page provides an explanation of each expense category for which the Debit Card may be used. Spending limits can be placed on selected 

expense areas. We recommend weekly or monthly restrictions in the Cash Bank and Snack Bar categories. Other categories involve purchases that are essential 

in nature or are small in size; therefore, restrictions are generally not used. On a monthly basis throughout the year, you will receive an itemized summary of the 

Debit Card activity. Be sure to complete the address portion of the Debit Card form so that the monthly statements are sent to the correct party. If your child is 

having trouble managing expenditures, please let us know and we can work with you to implement other controls and restrictions. 

An initial deposit, received before July 15, 2012, is required to activate your child’s Debit Card account by the beginning of the school year. Additional deposits 

may be made at any time throughout the year by sending payments to the Business Office. 

Please fill out and return the Debit Card form with your initial deposit by July 15, 2012. Your cooperation in meeting this deadline will greatly facilitate our ability 

to service your child’s needs in the opening days of school. 

The financially responsible parent or guardian may ask questions about or make changes to the account by phone, mail, fax or email (email preferred) to: 

Suffield Academy Business Office 

185 North Main Street 

Suffield, CT 06078 

Phone 

860-386-4455 

Fax 

860-668-2966 

Email 

pdellabernarda@suffieldacademy.org 

[ 

FORM: DEBIT / DUE: 07.15.12 

[




EXPENSE CATEGORIES 

1. CASH BANK: periodic cash withdrawals for student spending money. There is a limit of $50 per day per student. May be used to dispense a weekly 

allowance. Even if you do not want to use the regular allowance feature, it is convenient to allow a small monthly cash limit in order to cover emergency 

cash needs. Cash Bank allowance that is not drawn carries over and accumulates from week to week. 

2. BOOKSTORE: covers textbooks, school supplies, school clothing and logo memorabilia, phone cards, some personal toiletries and some athletic items. 

3. SNACK BAR: operated in the Student Union for the convenience of the students, it sells such items as soft drinks, juices, bagels, sandwiches and 

ice cream. 

4. ATHLETICS: required and optional athletic equipment sold through the athletic department; also covers uniforms and equipment which are lost, destroyed 

or not returned at the end of a season. 

5. STUDENT ACTIVITIES: includes the cost of transportation and entrance fees for trips and activities organized by the School. 

6. ACADEMIC: includes charges for testing (SAT, PSAT, AP) fees, tutoring, art materials, and other academic needs. 

7. HEALTH CENTER: includes charges for health services, such as immunizations, diagnostic testing, prescription medications and transportation for medical 

visits to off-campus providers. 

8. MAINTENANCE: covers charges for replacing lost dorm keys and repairs for damage. 

9. EXTRAORDINARY CASH: covers cash required for special expenses or in sums larger than the cash bank limit. Authorization for the use of this category 

requires an advance telephone call or written (mail, fax or email) permission sent by you to the Bookstore (or Business Office) before funds will be released. 

Permission to release funds will be accepted only from the student’s legal guardians. 

ESTIMATES AND RECOMMENDATIONS FOR SPENDING NEEDS AND LIMITS 

• Annual costs for required school supplies range from $200 to $400. Books for the fall term will be ordered online from one bookseller (www.mbsdirect.net). 

• Graphing calculators for upper level math courses cost in the $150 range. 

• School sweatshirts cost about $40, other shirts range from $12 to $30, hats cost about $15, outer wear can cost up to $70, computer software and hardware 

purchases are done by a special order arrangement. 

• Given the above three parameters of the Bookstore business, we suggest that you make an initial large deposit for school year startup. 

If there are insufficient funds in your child’s Debit Account to cover a requested or required transaction, the system will not allow the transaction to occur until 

additional funds are deposited into the account. 

[ 


[

[ 




ID# 

date of birth 


NAME OF STUDENT 

First Name Last Name Middle Name Year of Graduation 

Spending Restrictions: Please check the appropriate boxes 

Cash Bank 

Extraordinary Cash 

Bookstore 

Snack Bar 

Athletics 

Student Activities 

Academic 

Health Center 

Maintenance 

Unrestricted Use (maximum $50 per day) 

Weekly Allowance Amount 

(Note: Cash Bank allowance that is not drawn carries over and accumulates from week to week.) 

No Cash Withdrawal Allowed 

Restricted to parent/guardian confirmation for each request. 

Unrestricted Use 

Monthly Limit 

Only Cash/Check/Credit Card Purchases Allowed 

Unrestricted Use 

Weekly Limit 

Only Cash/Check Purchases Allowed 

Unrestricted 

Unrestricted 

Unrestricted 

Unrestricted 

Unrestricted 

Amount Enclosed 

(checks payable to Suffield Academy) 

Please provide address of person(s) responsible for Student Debit Card Account. Monthly Debit Card Account statements will be sent to this address: 

Name 

Street City State Zip Code 

Country 

Home Phone 

Email 

I/we understand that the maintenance of a balance in this account is my/our responsibility and that Suffield Academy will not, without my/our request, advance 

funds to cover a transaction unless there is a sufficient balance in the account. Please print this form and send it along with payment to Suffield Academy, 

Attn. Patrick Booth, 185 North Main Street, Suffield, CT 06078. 


Date 

By checking this box and entering the student ID number above, you are signing this document electronically. 

[ 


[



HEALTH CENTER POLICIES 

Most of the routine services of the Health Center are covered by tuition. Our professional nurses evaluate students for common maladies; over-the-counter 

medications are provided for students with headaches, colds, minor injuries and illnesses; ace bandages, crutches, ice packs, splints, and other similar supplies 

are also provided free of charge. 

Our medical director, Dr. Ross Porter, Board Certified in Pediatrics, comes to campus on Friday mornings and sees students who are ill or who need physicals, 

allergy injections, etc. The services of Dr. Porter and his associates are not covered by tuition. Please check with your insurance company to verify whether visits 

to see Dr. Porter will be covered. If a referral is needed from your child’s primary doctor to see Dr. Porter or another medical professional, please indicate this on 

the permission to treat form. The office of the medical professional your child visits will submit claims to your insurance company, but the ultimate responsibility 

for any bills incurred from medical professionals while your child is at school is yours. If bills remain outstanding for long periods of time, the Suffield Academy 

Business Office will deduct payment from your child’s debit card account. 

Prescription medications are obtained from Partner RX Pharmacy in East Windsor, CT; Drug Shop in Enfield, CT; or CVS Pharmacy in Suffield. The pharmacy is 

given your insurance information and will bill the insurance company directly. Co-payments or full reimbursement for services will be billed to the family directly 

or deducted from your child’s debit account. 

The Health Center coordinates transportation, which is provided by hired drivers, for medical appointments scheduled off-campus. The cost for this 

transportation is $20 per hour and will be deducted from the student’s debit card account. There will be a charge of $20 if a student does not show up to 

meet the driver at the scheduled time, unless the student notifies the Health Center at least two hours in advance. 

Flu vaccinations will be provided to your student if you desire. The cost of the vaccination is $25 and may be deducted from the student’s debit card account. 

Once the flu vaccinations have been ordered, payment is required. Please do not sign for if you intend on going to your own primary care provider as this fee is 

non-refundable. 

All narcotic and mood-altering prescription medications are kept in the Health Center and must be supplied in a blister pack from your pharmacy or from one 

of our local pharmacies. All medication must be in the original container from the pharmacy and labeled. Prescriptions that are self-administered must be 

accompanied by written instructions as to strength, dose and duration by the student’s physician. Prescriptions for controlled substance drugs and psychotropics 

must be kept at the Health Center and must be accompanied by the physician’s statement for administration. 

If you have questions regarding our financial or health care policies, please call Donna Rabbett, Director of Nursing at 860-386-4503 or 

email her at drabbett@suffieldacademy.org.

[ 




ID# 

date of birth 

Medical Insurance for Suffield Academy Students 

Suffield Academy requires that all enrolled students have insurance to cover emergency and other medical services that may be needed while they are at school. 

Suffield Academy offers an insurance package through the Student Insurance Division of the Mega Insurance Companies. This coverage is used by many 

independent schools, as well as colleges and universities. This Suffield Academy Insurance Plan is designed for students who do not have existing coverage. A 

brief description of the coverage follows this form. Your child will receive an identification card and full description of benefits if you enroll in the program for the 

2012-2013 school year. Our Health Center coordinates the interaction between health care providers and the insurance company. 

The premium cost for the plan offered is $1,720 and it covers the ten-month period from August 15, 2012, through June 14, 2013. 

If you have any questions, you may call the Business Office at 860-668-7315, or email pbooth@suffieldacademy.org. 

If you already have medical insurance coverage that will cover your child’s expenses while at Suffield Academy, and you have provided written 

documentation of that coverage (attach a copy of your insurance card to the Permission for Medical or Surgical Treatment form, or scan and email your 

insurance card), please check Box A, sign and return this Waiver/Enrollment form. If you cannot provide such documentation, you will be required 

to purchase the Suffield Academy Insurance Plan coverage. In order to enroll your child in the insurance program at Suffield, please check Box B on 

this Waiver/Enrollment form, sign the form and return it with your check (in U.S. dollars). 

Student Health Insurance Waiver/Enrollment 


First Name last Name Middle Name 

Please choose either option A (Waiver) or B (Enrollment) and sign the form below 

A: WAIVER (If you have existing medical insurance coverage) 

As parent (guardian), I certify that the student listed above has medical insurance which will cover expenses incurred by illness or injury while attending 

Suffield Academy. I have provided a copy of the front and back of the insurance card, which will be on file in the Suffield Academy Health Center. I decline 

enrollment in the Suffield Academy Insurance Plan. 

B: ENROLLMENT 

If you do not have existing medical insurance for your child, you must enroll in Suffield Academy Insurance Plan. Premium cost is $1,720 (for coverage 

through June 14, 2013). Please enroll the above named student in the medical insurance program offered through Suffield Academy. I have enclosed 

payment in U.S. Dollars for the premium cost of the Suffield Academy Insurance Plan; I understand that the coverage will begin August 15, 2012, or 

when I pay the premium, whichever date is later. Please print this form and send it along with payment to Suffield Academy, Attn. Patrick Booth, 

185 North Main Street, Suffield, CT 06078. 


Date 


[ 

FORM: INSURANCE / DUE: 07.15.12 

[

2012-2013 

STUDENT INJURY AND SICKNESS 

INSURANCE PLAN 

Designed Especially for Students of 

Suffield Academy 

Connecticut 

This Certificate does not provide coverage for: 

Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, 

bungee jumping, or flight in any kind of aircraft, except while riding as a 

passenger on a regularly scheduled flight of a commercial airline. 

06-BR-CT (Rev 09) 06-1806-1

Table of Contents 

Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 

Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 

Effective And Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 

Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 

Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 

Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 

Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 

UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 

Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 

Benefits for Accidental Ingestion of a Controlled Drug . . . . . . . . . . . . . . . . . . . . . . . . . .7 

Benefits for Hypodermic Needles or Syringes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 

Benefits for Reconstructive Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 

Benefits for Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 

Benefits for Mammography and Comprehensive Ultrasound Screening . . . . . . . .9 

Benefits for Ostomy Appliances and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

Benefits for Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

Benefits for Treatment of Tumors and Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 

Benefits for Prostate Cancer Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 

Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 

Benefits for Cancer Clinical Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 

Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 

Benefits for Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 

Benefits for Amino Acid Modified Preparations and 

Low Protein Modified Food Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 

Benefits for Lyme Disease Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 

Benefits for Isolation Care and Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . .11 

Benefits for Diabetic Outpatient Self-Management Training . . . . . . . . . . . . . . . . . . .12 

Benefits for Inpatient Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

Benefits for Treatment of Craniofacial Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

Benefits for Mental or Nervous Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

Benefits for Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 

Benefits for Infertility Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 

Benefits for Epidermolysis Bullosa Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 

Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 

Exclusions And Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 

General Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 

Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . .17 

Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back Cover

THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE 

COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR 

LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER 

ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO 

COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT 

CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR 

MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE 

COST OF SERVICES EXCEEDS THOSE LIMITS, THE INSURED 

AND NOT THE COMPANY IS RESPONSIBLE FOR PAYMENT OF 

THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE 

SPECIFIED IN THE SCHEDULE OF BENEFITS. 

Privacy Policy 

We know that your privacy is important to you and we strive to protect the confidentiality of 

your nonpublic personal information. We do not disclose any nonpublic personal information 

about our customers or former customers to anyone, except as permitted or required by law. 

We believe we maintain appropriate physical, electronic and procedural safeguards to 

ensure the security of your nonpublic personal information. You may obtain a copy of our 

privacy practices by calling us toll-free at 800-767-0700 or by visiting us at www.uhcsr.com. 

Eligibility 

All Domestic students registered for credit courses are eligible to enroll in this insurance 

Plan. 

All International students registered for credit courses are automatically enrolled in this 

insurance Plan at registration, unless proof of comparable coverage is furnished. 

Students must actively attend classes for at least the first 31 days after the date for which 

coverage is purchased. The Company maintains its right to investigate student status and 

attendance records to verify that the policy Eligibility requirements have been met. If the 

Company discovers the Eligibility requirements have not been met, its only obligation is to 

refund premium. 

Alternative Coverage - If you do not meet the Eligibility requirements of the Plan, please 

call 1-800-406-2338 for more information on alternative coverage. This information can 

also be accessed at http://www.goldenrulehealth.com/studentresources. 

Effective And Termination Dates 

The Master Policy on file at the school becomes effective at 12:01 a.m., August 15, 2012. 

Coverage becomes effective on the first day of the period for which premium is paid or the 

date the enrollment form and full premium are received by the Company (or its authorized 

representative), whichever is later. The Master Policy terminates at 11:59 p.m., June 15 

2013. Coverage terminates on that date or at the end of the period through which premium 

is paid, whichever is earlier. 

Refunds of premiums are allowed only upon entry into the armed forces. 

The Policy is a Non-Renewable One Year Term Policy. 

1

Extension of Benefits After Termination 

The coverage provided under the Policy ceases on the Termination Date. However, if an 

Insured is Totally Disabled on the Termination Date from a covered Injury or Sickness for 

which benefits were paid before the Termination Date, Covered Medical Expenses for such 

Injury or Sickness will continue to be paid as long as the condition continues but not to 

exceed 90 days after the Termination Date. 

The total payments made in respect of the Insured for such condition both before and after 

the Termination Date will never exceed the Maximum Benefit. 

After this "Extension of Benefits" provision has been exhausted, all benefits cease to exist, 

and under no circumstances will further payments be made. 

Pre-Admission Notification 

UMR Care Management should be notified of all Hospital Confinements prior to admission. 

1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATION: 

The patient, Physician or Hospital should telephone 1-877-295-0720 at least five 

working days prior to the planned admission. 

2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, 

patient's representative, Physician or Hospital should telephone 1-877-295-0720 

within two working days of the admission to provide notification of any admission due 

to Medical Emergency. 

UMR Care Management is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 

p.m. C.S.T., Monday through Friday. Calls may be left on the Customer Service Department's 

voice mail after hours by calling 1-877-295-0720. 

IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise 

payable under the policy; however, pre-notification is not a guarantee that benefits will be 

paid. 

2

Schedule of Medical Expense Benefits 

Injury and Sickness 

Up to $250,000 Maximum Benefit (For each Injury or Sickness) 

Coinsurance 100% 

The policy provides benefits for 100% of Usual and Customary Charges incurred by an 

Insured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of 

$250,000 for each Injury or Sickness. 

Usual & Customary Charges are based on data provided by FAIR Health, Inc. using the 

90th percentile based on location of provider. 

Benefits will be paid up to the Maximum Benefit for each service as scheduled below. 

Covered Medical Expenses include: 

max = maximum 

INPATIENT 

U&C = Usual & Customary Charges 

Room & Board Expense, daily semi-private room rate; and 

general nursing care provided by the Hospital. 

Hospital Miscellaneous Expenses, such as the cost of 

the operating room, laboratory tests, x-ray examinations, 

anesthesia, drugs (excluding take home drugs) or 

medicines, therapeutic services, and supplies. In computing 

the number of days payable under this benefit, the date of 

admission will be counted, but not the date of discharge. 

Intensive Care 

Physiotherapy 

Surgeon’s Fees, in accordance with data provided by 

FAIR Health, Inc. If two or more procedures are performed 

through the same incision or in immediate succession at 

the same operative session, the maximum amount paid will 

not exceed 50% of the second procedure and 50% of all 

subsequent procedures. 

Assistant Surgeon 

Anesthetist, professional services administered in 

connection with inpatient surgery. 

Registered Nurse’s Services, private duty nursing care. 

Physician’s Visits, benefits are limited to one visit per day 

and do not apply when related to surgery. 

Pre-Admission Testing, payable within 7 working days 

prior to admission. 

Mental or Nervous Conditions 

U&C 

U&C 

U&C 

U&C 

U&C 

30% of Surgery Allowance 

U&C 

U&C 

U&C 

U&C 

Paid as any other Sickness 

3

OUTPATIENT 

Surgeon’s Fees, in accordance with data provided by FAIR 

Health, Inc. If two or more procedures are performed 

through the same incision or in immediate succession at the 

same operative session, the maximum amount paid will not 

exceed 50% of the second procedure and 50% of all 

subsequent procedures. 

Day Surgery Miscellaneous, related to scheduled surgery 

performed in a Hospital, including the cost of the operating 

room; laboratory tests and x-ray examinations, including 

professional fees; anesthesia; drugs or medicines; and 

supplies. Usual and Customary Charges for Day Surgery 

Miscellaneous are based on the Outpatient Surgical Facility 

Charge Index. 

Assistant Surgeon 

U&C 

U&C 

Anesthetist, professional services administered in U&C 

connection with outpatient surgery. 

Physician’s Visits, benefits are limited to one visit per day. U&C 

Benefits for Physician’s Visits do not apply when related to 

surgery or Physiotherapy. 

Physiotherapy/ Occupational Therapy, benefits are 

limited to one visit per day. Review of Medical Necessity will 

be performed after 12 visits per Injury or Sickness. 

Medical Emergency Expenses, use of the emergency 

room and supplies. Treatment must be rendered within 72 

hours from time of Injury or first onset of Sickness. 

Diagnostic X-ray & Laboratory Services 

Radiation Therapy 

Chemotherapy 

Tests & Procedures, diagnostic services and medical 

procedures performed by a Physician, other than Physician’s 

Visits, Physiotherapy, X-Rays and Lab Procedures. 

Injections, when administered in the Physician’s office and 

charged on the Physician’s statement. 

Prescription Drugs, UnitedHealthcare Network Pharmacy, 

$0 copay per prescription tier 1, tier 2, tier 3 / up to a 31 day 

supply per prescription. Out-of-Network prescription drugs 

paid at 100% actual billed charges, $0 Deductible per 

prescription up to a 31 day supply, $1,500 maximum Per 

Policy Year combined in and out of network. Diabetic insulin 

and supplies are not subject to the $1,500 prescription drug 

maximum benefit. See Benefits for Diabetes. 

30% of Surgery Allowance 

U&C 

U&C 

U&C 

U&C 

U&C 

U&C 

U&C 

$1,500 max 

(Per Policy Year) 

Mental or Nervous Conditions 


4

OTHER 

Ambulance Services, when medically necessary transport 

to a Hospital. 

Durable Medical Equipment, a written prescription must 

accompany the claim when submitted. Replacement 

equipment is not covered. 

5 

Maximum allowable rate 

established by the 

Department of Public 

Health 

U&C 

Alcoholism / Drug Abuse 

See Benefit for Treatment 

of Mental or Nervous 

Conditions 

Consultant Physician Fees, when requested and U&C 

approved by the attending Physician. 

Dental Treatment, made necessary by Injury to Sound, U&C 

Natural Teeth; Exception: See Benefits for In-patient Dental 

Services. 

Maternity & Complications of Pregnancy 


Interscholastic Sports 

Paid as any other Injury 

Eating Disorders 

Home Health Care 

Preventive Care, Preventive Care benefits are based on 

guidelines from UnitedHealthcare, the U.S. Preventive 

Services Task Force and recommendations of the National 

Immunizations Program of the Centers for Disease Control 

Prevention, except as specifically provided in the Mandated 

Benefit. 

U&C / $5,000 max 

See Benefits for Home 

Health Care 

U&C 

Urgent Care Clinic Fee, Benefits are limited to the Urgent U&C 

Care Clinic fee billed by the Urgent Care Clinic/Hospital. All 

other services rendered during the visit are payable as 

specified in the Schedule of Benefits. 

Maternity Testing 

This policy does not cover routine, preventive or screening examinations or testing unless 

Medical Necessity is established based on medical records. The following maternity routine 

tests and screening exams will be considered if all other policy provisions have been met: 

Initial screening at first visit – Pregnancy test: Urine human chorionic gonatropin (HCG), 

Asymptomatic bacteriuria: Urine culture, Blood type and Rh antibody, Rubella, Pregnancyassociated 

plasma protein-A (PAPPA) (first trimester only), Free beta human chorionic 

gonadotrophin (hCG) (first trimester only), Hepatitis B: HBsAg, Pap smear, Gonorrhea: Gc 

culture, Chlamydia: chlamydia culture, Syphilis: RPR, HIV: HIV-ab, and Coombs test; Each 

visit – Urine analysis; Once every trimester – Hematocrit and Hemoglobin; Once during 

first trimester – Ultrasound; Once during second trimester – Ultrasound (anatomy 

scan); Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein 

(AFP), Estriol, hCG, inhibin-a; Once during second trimester if age 35 or over - 

Amniocentesis or Chorionic villus sampling (CVS); Once during second or third 

trimester – 50g Glucola (blood glucose 1 hour postprandial); and Once during third 

trimester - Group B Strep Culture. Pre-natal vitamins are not covered. For additional 

information regarding Maternity Testing, please call the Company at 1-800-767-0700.

UnitedHealthcare Network Pharmacy Benefits 

Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL) 

when dispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supply 

limits and copayments that vary depending on which tier of the PDL the outpatient drug is 

listed. There are certain Prescription Drugs that require your Physician to notify us to verify 

their use is covered within your benefit. 

Prescription Drugs which require notification are: 

Actiq, Anzemet, Avita-Penderm, Avodart, Copegus, Differin-Gladerma, Diflucan, Elidel, 

Emend, Genotropin, Humatrope, Increlex, Infergen, Intron-A, Iplex, Kytril, Lamisil, Lotronex, 

Norditropin, Nutropin, Nutropin AQ, Nutropin Depot, PEG-Intron, Pegasys, Proscar, Protopic, 

Protropin, Provigil, Raptiva, Regranex, Relenza, Retin-A, Retin-A Micro Ortho, Rebetol, 

Rebetron, Restasis, Revatio, Roferon, Sporanox, Saizen, Serostim, Tamiflu, Tazorac, Tracleer, 

Ventavis, Wellbutrin SR, Wellbutrin XL, Zelnorm, Zofran, Zorbtive. 

You are responsible for paying the applicable copayments. Your copayment is determined 

by the tier to which the Prescription Drug Product is assigned on the PDL. Tier status may 

change periodically and without prior notice to you. Please call 877-417-7345 for the most 

up-to-date tier status. 

$0 copay per prescription or refill for tier 1 Prescription Drug up to 31 day supply. 



Your maximum allowed benefit is $1,500 Per Policy Year. 

Diabetic insulin and supplies are not subject to the $1,500 Prescription Drugs maximum 

benefit but are subject to the overall Policy Maximum Benefit. 

Please present your ID card to the network pharmacy when the prescription is filled. If you 

do not present the card, you will need to pay for the prescription and then submit a 

reimbursement form for prescriptions filled at a network pharmacy along with the paid 

receipt in order to be reimbursed. To obtain reimbursement forms, or for information about 

mail-order prescriptions or network pharmacies, please visit www.uhcsr.com and log in to 

your online account or call 877-417-7345. 

When prescriptions are filled at pharmacies outside the network, the Insured must pay for 

the prescriptions out-of-pocket and submit the receipts for reimbursement to 

UnitedHealthcare StudentResources, P.O. Box 809025, Dallas, TX 75380-9025. See the 

Schedule of Benefits for the benefits payable at out-of-network pharmacies. 

Additional Exclusions 

In addition to the policy Exclusions and Limitations, the following Exclusions apply to 

Network Pharmacy Benefits: 

1. Coverage for Prescription Drug Products for the amount dispensed (days' supply or 

quantity limit) which exceeds the supply limit. 

2. Experimental or Investigational Services or Unproven Services and medications; 

medications used for experimental indications and/or dosage regimens determined 

by the Company to be experimental, investigational or unproven. 

3. Compounded drugs that do not contain at least one ingredient that has been 

approved by the U.S. Food and Drug Administration and requires a Prescription Order 

or Refill. Compounded drugs that are available as a similar commercially available 

Prescription Drug Product. Compounded drugs that contain at least one ingredient 

that requires a Prescription Order or Refill are assigned to Tier-3. 

6

4. Drugs available over-the-counter that do not require a Prescription Order or Refill by 

federal or state law before being dispensed, unless the Company has designated the 

over-the counter medication as eligible for coverage as if it were a Prescription Drug 

Product and it is obtained with a Prescription Order or Refill from a Physician. 

Prescription Drug Products that are available in over-the-counter form or comprised 

of components that are available in over-the-counter form or equivalent, unless a 

Medical Necessity. Certain Prescription Drug Products that the Company has 

determined are Therapeutically Equivalent to an over-the-counter drug, unless 

Medical Necessity. Such determinations may be made up to six times during a 

calendar year, and the Company may decide at any time to reinstate Benefits for a 

Prescription Drug Product that was previously excluded under this provision. 

5. Any product for which the primary use is a source of nutrition, nutritional supplements, 

or dietary management of disease, even when used for the treatment of Sickness or 

Injury, except as required by state mandate. 

Definitions: 

Network Pharmacy means a pharmacy that has: 

• Entered into an agreement with the Company or an organization contracting on our 

behalf to provide Prescription Drug Products to Insured Persons. 

• Agreed to accept specified reimbursement rates for dispensing Prescription Drug 

Products. 

• Been designated by the Company as a Network Pharmacy. 

Prescription Drug or Prescription Drug Product means a medication, product or device 

that has been approved by the U.S. Food and Drug Administration and that can, under 

federal or state law, be dispensed only pursuant to a Prescription Order or Refill. A 

Prescription Drug Product includes a medication that, due to its characteristics, is 

appropriate for self-administration or administration by a non-skilled caregiver. For the 

purpose of the benefits under the policy, this definition includes insulin. 

Prescription Drug List means a list that categorizes into tiers medications, products or 

devices that have been approved by the U.S. Food and Drug Administration. This list is 

subject to the Company’s periodic review and modification (generally quarterly, but no more 

than six times per calendar year). The Insured may determine to which tier a particular 

Prescription Drug Product has been assigned through the Internet at www.uhcsr.com or call 

Customer Service at 1-877-417-7345. 

Mandated Benefits 

Benefits for Accidental Ingestion of a Controlled Drug 

Benefits will be paid for accidental ingestion or consumption of a controlled drug as 

required by Connecticut statute. When inpatient treatment in a Hospital, whether or not 

operated by the State, is required as a result of accidental ingestion or consumption of a 

controlled drug, benefits will be paid for the Usual and Customary Charges incurred up to 

a maximum of 30 days Hospital Confinement. Benefits will be paid for outpatient treatment 

resulting from accidental ingestion or consumption of a controlled drug up to a maximum 

of $500 for any one accident. 

Benefits for Hypodermic Needles or Syringes 

Benefits will be paid for the Usual and Customary Charges incurred for hypodermic needles 

or syringes prescribed by a licensed Physician for the purpose of administering medications 

for any Injury or Sickness, provided such medications are covered under the policy. 

Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any 

other provisions of the policy. 

7

Benefits for Reconstructive Breast Surgery 

Benefits will be paid for the Usual and Customary Charges incurred for reconstructive 

surgery on each breast on which a mastectomy has been performed, and reconstructive 

surgery on a nondiseased breast to produce a symmetrical appearance. Reconstructive 

surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty 

and mastopexy. 



Benefits for Home Health Care 

Benefits will be paid as specified below for Injury or Sickness for home health care to 

residents in Connecticut. 

Benefits payable shall be limited to eighty visits in any calendar year or in any continuous 

period of twelve months for each Insured, except in the case of an Insured diagnosed by a 

Physician as terminally ill with a prognosis of six months or less to live, the yearly benefit for 

medical social services shall not exceed two hundred dollars ($200.00). Each visit by a 

representative of a home health agency shall be considered as one home health care visit; 

four hours of home health aide service shall be considered as one home health care visit. 

Home health care benefits are subject to an annual Deductible of fifty dollars ($50.00) for 

each Insured and will be subject to a coinsurance provision of not less than seventy-five 

percent (75%) of the Usual and Customary Charges for such services. If an Insured is 

eligible for home health care coverage under more than one policy, the home health care 

benefits shall only be provided by that Policy which would have provided the greatest 

benefits for hospitalization if the person had remained or had been hospitalized. 

"Home health care" means the continued care and treatment of a covered person who is 

under the care of a Physician if: 

(1) continued hospitalization would otherwise have been required if home health care was 

not provided, except in the case of an Insured diagnosed by a Physician as terminally 

ill with a prognosis of six months or less to live, and, 

(2) the plan covering the home health care is established and approved in writing by such 

Physician within seven days following termination of a hospital confinement as a 

resident inpatient for the same or a related condition for which the Insured was 

hospitalized, except that in the case of an Insured diagnosed by a Physician as 

terminally ill with a prognosis of six months or less to live, such plan may be so 

established and approved at any time irrespective of whether such Insured was so 

confined or, if such Insured was so confined, irrespective of such seven-day period, 

and 

(3) such home health care is commenced within seven days following discharge, except 

in the case of a covered person diagnosed by a Physician as terminally ill with a 

prognosis of six months or less to live. 

Home health care shall be provided by a home health agency. "Home health agency" 

means an agency or organization which meets each of the following requirements: 

(1) It is primarily engaged in and is federally certified as a home health agency and duly 

licensed by the appropriate licensing authority to provide nursing and other 

therapeutic services. 

(2) Its policies are established by a professional group associated with such agency or 

organization, including at least one Physician and at least one Registered Nurse, to 

govern the services provided. 

(3) It provides for full-time supervision of such services by a Physician or by a Registered 

Nurse. 

(4) It maintains a complete medical record on each patient. 

(5) It has an administrator. 

8

Home health care shall consist of, but shall not be limited to, the following: 

(1) Part-time or intermittent nursing care by a Registered Nurse or by a licensed practical 

nurse under the supervision of a Registered Nurse, if the services of a Registered 

Nurse are not available; 

(2) Part-time or intermittent home health aide services, consisting primarily of patient care 

of a medical or therapeutic nature by other than a Registered Nurse or licensed 

practical nurse; 

(3) Physical, occupational or speech therapy; 

(4) Medical supplies, drugs and medicines prescribed by a Physician and laboratory 

services to the extent such charges would have been covered under the Policy or 

contract if the Insured had remained or had been confined in the Hospital; 

(5) Medical social services provided to or for the benefit of a covered person diagnosed 

by a Physician as terminally ill with a prognosis of six months or less to live. "Medical 

social services" mean services rendered, under the direction of a Physician by a 

qualified social worker, including but not limited to: 

(A) assessment of the social, psychological and family problems related to or arising out 

of such covered person's illness and treatment; 

(B)appropriate action and utilization of community resources to assist in resolving such 

problems; 

(C)participation in the development of the overall plan of treatment for such Insured. 

Benefits shall be subject to all other limitations and provisions of the policy. 

Benefits for Mammography and Comprehensive Ultrasound Screening 

Benefits will be paid the same as any other Covered Medical Expenses as shown on the 

Schedule of Benefits for mammographic examinations to any woman insured under this 

policy which are equal to the following requirements: 1) a baseline mammogram for any 

woman who is thirty-five to thirty-nine years of age, inclusive; and 2) a mammogram every 

year for any woman who is forty years of age or older. 

Additional benefits will be provided for comprehensive ultrasound screening of an entire 

breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue 

based on the Breast Imaging Reporting and Data System established by the American 

College of Radiology or if a woman is believed to be at increased risk for breast cancer due 

to family history or prior personal history of breast cancer, positive genetic testing or other 

indications as determined by a woman’s Physician or advanced practice Registered Nurse. 



Benefits for Ostomy Appliances and Supplies 

Benefits will be paid for the Usual and Customary Charges for Medically Necessary 

appliances and supplies relating to an ostomy including, but not limited to, collection 

devices, irrigation equipment and supplies, skin barriers and skin protectors up to a 

maximum benefit of $1,000 per Policy Year. 

"Ostomy" shall include colostomy, ileostomy and urostomy. 



Benefits for Autism Spectrum Disorders 

Benefits will be paid the same as any other Sickness for physical therapy, speech therapy, 

and occupational therapy services for the treatment of Autism Spectrum Disorders, as set 

forth in the most recent edition of the American Psychiatric Association’s “Diagnostic and 

Statistical Manual of Mental Disorders”. 



9

Benefits for Treatment of Tumors and Leukemia 

Benefits will be paid the same as any other Sickness for the surgical removal of tumors and 

for treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, cost 

of any non-dental prosthesis, including any maxillofacial prosthesis used to replace 

anatomic structures lost during treatment for head and neck tumors or additional 

appliances essential for the support of such prosthesis and outpatient chemotherapy 

following surgical procedures in connection with the treatment of tumors, and a wig if 

prescribed by a licensed oncologist for a patient who suffers hair loss as a result of 

chemotherapy. 

Benefits per policy year shall be at least $1,000 for the removal of any breast implant, 

$500 for the surgical removal of tumors, $500 for reconstructive surgery, $500 for 

outpatient chemotherapy and $300 for prosthesis, except that for purposes of the surgical 

removal of breasts due to tumors the yearly benefit for prosthesis shall be at least $300 for 

each breast removed, and $350 for a wig. 

If the policy provides benefits for Prescription Drugs, benefits will be provided for prescribed 

orally administered anticancer medications on a basis that is no less favorable than 

intravenously administered anticancer medications. 



Benefits for Prostate Cancer Testing 

Benefits will be paid the same as any other Sickness for laboratory and diagnostic tests, 

including, but not limited to, prostate specific antigen (PSA) tests to screen for prostate 

cancer for Insureds who are symptomatic, whose biological father or brother has been 

diagnosed with prostate cancer, and for all Insureds fifty (50) years of age or older. 



Benefits for Colorectal Cancer Screening 

Benefits will be paid the same as any other Sickness for colorectal cancer screening, 

including, but not limited to: (1) an annual fecal occult blood test, and (2) colonoscopy, 

flexible sigmoidoscopy or radiologic imaging, in accordance with the recommendations 

established by the American College of Gastroenterology, after their consultation with the 

American Cancer Society, based on the ages, family histories and frequencies provided in 

the recommendations. 



Benefits for Cancer Clinical Trial 

Benefits will be paid the same as any other Sickness for the medically necessary treatment 

for Routine Patient Care Costs associated with Cancer Clinical Trials. 

Benefits are subject to all Deductible, copayment, terms, conditions, restrictions, Exclusions 

and Limitations of the policy. 

A detailed description of the benefits and restrictions for Cancer Clinical Trials is available 

in the Master Policy on file at the school or by calling the Company at 1-800-767-0700. 

Benefits for Diabetes 

Benefits will be paid the same as any other Sickness for the treatment of insulin-dependent 

diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes. Such 

coverage shall include Medically Necessary equipment, in accordance with the Insured 

Person's treatment plan, drugs and supplies prescribed by a Physician. 

If the policy contains a Prescription Drugs maximum benefit, diabetic insulin and supplies 

shall not be subject to the Prescription Drugs maximum benefit specified in the Schedule 

of Benefits. Benefits shall be subject to all other Deductible, copayments, coinsurance, 

limitations, or any other provisions of the policy. 

10

Benefits for Postpartum Care 

If an Insured and Newborn Infant are discharged from inpatient care less than forty-eight 

hours after a vaginal delivery or less than ninety-six hours after a cesarean delivery, benefits 

will be provided on the same basis as any other Covered Medical Expenses as shown on 

the Schedule of Benefits for a follow-up visit within forty-eight hours of discharge and an 

additional follow-up visit within seven days of discharge. Any decision to shorten the length 

of inpatient stay to less than forty-eight hours after a vaginal delivery or ninety-six hours 

after a cesarean delivery shall be made by the Physician after conferring with the Insured. 

Follow-up services shall include, but not be limited to, physical assessment of the Newborn, 

parent education, assistance and training in breast or bottle feeding, assessment of the 

home support system and the performance of any Medically Necessary and appropriate 

clinical tests. Such services shall be consistent with protocols and guidelines developed by 

attending providers or by national pediatric, obstetric and nursing professional organizations 

for these services and shall be provided by qualified health care personnel trained in 

postpartum maternal and Newborn pediatric care. 



Benefits for Amino Acid Modified Preparations and 

Low Protein Modified Food Products 

Benefits will be paid the same as any other outpatient Prescription Drug for Amino Acid 

Modified Preparations and Low Protein Modified Food Products for the treatment of 

Inherited Metabolic Diseases if the Amino Acid Modified Preparations or Low Protein 

Modified Food Products are prescribed for the therapeutic treatment of Inherited Metabolic 

Diseases and are administered under the direction of a Physician. 

If the policy does not provide benefits for outpatient Prescription Drugs, benefits will be 

provided subject to the policy maximum benefit including any Deductible, copayment or 

coinsurance requirements. 

"Inherited metabolic disease" means (A) disease for which newborn screening is required 

under Connecticut Statute Title 38a, Chapter 700c, Section 19a-55, and (B) Cystic Fibrosis. 

"Low protein modified food product: means a product formulated to have less than one 

gram of protein per serving and intended for the dietary treatment of an inherited metabolic 

disease under the direction of a physician. 

"Amino acid modified preparation" means a product intended for the dietary treatment of 

an inherited metabolic disease under the direction of a Physician. 



Benefits for Lyme Disease Treatment 

Benefits will be paid the same as any other Sickness for Lyme disease treatment including 

not less than thirty days of intravenous antibiotic therapy, sixty days of oral antibiotic therapy, 

or both, and shall provide benefits for further treatment if recommended by a Physician. 



Benefits for Isolation Care and Emergency Services 

Benefits will be paid the same as any other Injury or Sickness for isolation care and 

emergency services provided by the state’s mobile field Hospital. 



11

Benefits for Diabetic Outpatient Self-Management Training 

Benefits will be paid the same as any other Sickness for outpatient self-management 

training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational 

diabetes and non-insulin-using diabetes if the training is prescribed by a Physician. 

Outpatient self-management training includes, but is not limited to, education and medical 

nutrition therapy. Diabetes self-management training shall be provided by a Physician, as 

defined in the Policy, trained in the care and management of diabetes and authorized to 

provide such care within the scope of the Physician's practice. 

Covered Medical Expenses shall include: 

1) Initial training visits provided to an Insured after the Insured is initially diagnosed 

with diabetes that is Medically Necessary for the care and management of diabetes, 

including, but not limited to, counseling in nutrition and the proper use of equipment 

and supplies for the treatment of diabetes, up to a maximum of ten hours. 

2) Training and education that is Medically Necessary as a result of a subsequent 

diagnosis by a Physician of a significant change in the Insured's symptoms or 

condition which requires modification of the Insured's program of self-management 

of diabetes, up to a maximum of four hours. 

3) Training and education that is Medically Necessary because of the development of 

new techniques and treatment for diabetes up to a maximum of four hours. 



Benefits for Inpatient Dental Services 

Benefits will be paid the same as any other Sickness for general anesthesia, nursing and 

related Hospital services provided in conjunction with inpatient, outpatient or one day dental 

services if the following conditions are met: 

1) The anesthesia, nursing and related Hospital services are deemed Medically 

Necessary by the treating Physician. 

2) The Insured is either a) a person who is determined by a Physician to have a dental 

condition of significant dental complexity that it requires certain dental procedures 

to be performed in a Hospital, or b) a person who has a developmental disability, as 

determined by a Physician, that places the person at serious risk. 

The expense of anesthesia, nursing and related Hospital services shall be deemed a 

Covered Medical Expense and shall not be subject to any limits on dental benefits in the 

Policy. 



Benefits for Treatment of Craniofacial Disorders 

Benefits will be paid the same as any other Sickness for medically necessary orthodontic 

processes and appliances for the treatment of craniofacial disorders for Insureds eighteen 

years of age or younger. The processes and appliances must be prescribed by a craniofacial 

team recognized by the American Cleft Palate-Craniofacial Association. No benefits are 

provided for cosmetic surgery. 



Benefits for Mental or Nervous Conditions 

Benefits will be paid the same as any other Sickness for the diagnosis and treatment of 

Mental or Nervous Conditions. 



12

Benefits for Pain Management 

Benefits will be paid the same as any other Sickness for Pain treatment ordered by a Pain 

Management Specialist, which may include all means Medically Necessary to make a 

diagnosis and develop a treatment plan including the use of necessary medications and 

procedures. 

"Pain" means a sensation in which a person experiences severe discomfort, distress or 

suffering due to provocation of sensory nerves, and "pain management specialist" means a 

Physician who is credentialed by the American Academy of Pain Management or who is a 

board-certified anesthesiologist, neurologist, oncologist or radiation oncologist with 

additional training in pain management. 



Benefits for Infertility Treatment 

Benefits will be paid the same as any other Sickness for an Insured Person for the 

medically necessary expenses of the diagnosis and treatment of Infertility, including, but not 

limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo 

lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and 

low tubal ovum transfer. Such infertility treatment must be performed at facilities that 

conform to the standards and guidelines developed by the American Society of 

Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility. 

For the purposes of this section “Infertility” means the condition of a presumably healthy 

individual who is unable to conceive or produce conception or sustain a successful 

pregnancy during a one year period. 

Benefits are subject to the following limitations: 

1) Benefits are available up to the Insured Person’s fortieth (40) birthday. 

2) Benefits for ovulation induction are subject to a lifetime limit of four (4) cycles. 

3) Benefits for intrauterine insemination are subject to a lifetime limit of three (3) cycles. 

4) Benefits for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian 

transfer, and tubal ovum transfer are subject to a lifetime limit of two (2) cycles, with 

not more than two (2) embryo implantations per cycle. 

5) Benefits for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian 

transfer and low tubal ovum transfer are payable only to those Insured Persons who: 

a) Have been unable to conceive or produce conception or sustain a successful 

pregnancy through less expensive and medically viable infertility treatment or 

procedures covered by this policy. However benefits will not be denied on this basis 

for any Insured Person who forgoes a particular infertility treatment or procedure if 

the Insured Person’s Physician determines that such treatment or procedure is 

likely to be unsuccessful. 

b) Have been covered under the school’s student insurance policy for at least 12 

months. 

c) Provide disclosure of any previous infertility treatment or procedures for which such 

Insured Person received coverage under a different health insurance policy. 



13

Benefits for Epidermolysis Bullosa Treatment 

Benefits will be paid for the Usual and Customary Charges for wound-care supplies that 

are Medically Necessary for the treatment of Epidermolysis Bullosa provided such benefits 

are administered under the direction of a Physician. 

“Epidermolysis Bullosa” is a genetic disorder caused by a mutation in the keratin gene. The 

disorder is characterized by the presence of extremely fragile skin and recurrent blister 

formation, resulting from minor mechanical friction or trauma. 



Definitions 

Injury means accidental bodily injuries sustained by the Insured Person which: 1) are the 

direct cause, independent of disease or bodily infirmity or any other cause; 2) are treated 

by a Physician within 30 days after the date of accident; and occurs while this policy is in 

force, subject to the policy Pre-existing Condition provisions. Covered Medical Expenses 

incurred as a result of an injury that occurred prior to this policy's Effective Date will be 

considered a Sickness under this policy, subject to the policy Pre-existing Condition 

provisions. 

Sickness means sickness or disease of the Insured Person which causes loss while the 

Insured Person is covered under this policy, subject to the policy Pre-existing Condition 

provisions. All related conditions and recurrent symptoms of the same or a similar condition 

will be considered one sickness. Covered Medical Expenses incurred as a result of an Injury 

that occurred prior to this policy's Effective Date will be considered a sickness under this policy. 

Totally Diabled means a condition of a Named Insured which, because of Sickness or 

Injury, renders the Insured unable to actively attend class. 

Usual and Customary Charges means a reasonable charge which is: 1) usual and 

customary when compared with the charges made for similar services and supplies; and 2) 

made to persons having similar medical conditions in the locality where service is rendered. 

No payment will be made under this policy for any expenses incurred which in the judgment 

of the Company are in excess of Usual and Customary Charges. 

Exclusions And Limitations 

No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; 

or b) treatment, services or supplies for, at, or related to: 

1. Acupuncture, allergy testing; 

2. Biofeedback; 

3. Circumcision; 

4. Congenital conditions, except as specifically provided for Newborn or adopted Infants; 

5. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which 

benefits are otherwise payable under this policy or for newborn or adopted children; 

6. Dental treatment, except as specifically provided in the Policy; 

7. Elective Surgery or Elective Treatment; 

8. Elective abortion; 

9. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or 

contact lenses; except when due to a disease process; 

10. Foot care including: care of corns, bunions (except capsular or bone surgery) and 

calluses; 

11. Hearing examinations or hearing aids or other treatment for hearing defects and 

problems. "Hearing defects" means any physical defect of the ear which does or can 

impair normal hearing, apart from the disease process; 

12. Hirsutism; alopecia; 

14

13. Immunizations, except as specifically provided in the policy; preventive medicines or 

vaccines, except where required for treatment of a covered Injury, except as 

specifically provided in the policy; 

14. Injury or Sickness for which benefits are paid or payable under any Workers' 

Compensation or Occupational Disease Law or Act, or similar legislation; 

15. Lipectomy; 

16. Organ transplants; 

17. Participation in a riot, civil disorder or a felony, except when Injury occurs when the 

Insured Person has an elevated blood alcohol content or when under the influence of 

intoxication liquor or any drug or both. Participation means to voluntarily take a part or 

share with others assembled together in some activity. Riot means a violent public 

disturbance of the peace by a number of persons assembled together; 

18. Prescription Drugs, services or supplies as follows, except as specifically provided in 

the policy: 

a) Therapeutic devices or appliances, including: hypodermic needles and syringes, 

except for hypodermic needles or syringes prescribed by a Physician for the 

purpose of administering medications for medical conditions, provided such 

medications are covered under the policy, support garments and other non-medical 

substances; 

b) Immunization agents, biological sera, blood or blood products administered on an 

outpatient basis; 

c) Drugs labeled, "Caution-limited by federal law to investigational use" or 

experimental drugs except for drugs for the treatment of cancer that have not been 

approved by the Federal Food and Drug Administration, provided the drug is 

recognized for treatment of the specific type of cancer for which the drug has been 

prescribed in one of the following established reference compendia: (1) The U.S. 

Pharmacopeia Drug Information Guide for the Health Care Professional (USP DI); 

(2) The American Medical Association's Drug Evaluations (AMA DE); or (3) The 

American Society of Hospital Pharmacist's American Hospital Formulary Service 

Drug Information (AHFS-DI); 

d) Products used for cosmetic purposes; 

e) Drugs used to treat or cure baldness; anabolic steroids used for body building; 

f) Anorectics- drugs used for the purpose of weight control; 

g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, 

Profasi, Metrodin, Serophene, or Viagra; except as specifically provided in the 

Benefits for Infertility Treatment; 

h) Growth hormones; or 

i) Refills in excess of the number specified or dispensed after one (1) year of date of 

the prescription; 

19. Reproductive/Infertility services including but not limited to: family planning; fertility 

tests; infertility (male or female), including any services or supplies rendered for the 

purpose or with the intent of inducing conception; except as specifically provided in 

the Benefits for Infertility Treatment; 

20. Routine Newborn Infant Care, well-baby nursery and related Physician charges in 

excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; except as 

specifically provided in the policy; 

21. Routine physical examinations and routine testing; preventive testing or treatment; 

screening exams or testing in the absence of Injury or Sickness; except as specifically 

provided in the policy; 

15

22. Skeletal irregularities of one or both jaws, including orthognathia and mandibular 

retrognathia, except as specifically provided in the Benefits for Treatment of Craniofacial 

Disorders; 

23. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee 

jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly 

scheduled flight of a commercial airline; 

24. Sleep disorders; 

25. Unless specifically covered under Benefits for Mental or Nervous Conditions, Injury 

resulting from suicide or attempted suicide while sane or insane (including intentional 

drug overdose); or intentionally self-inflicted Injury; 

26. Supplies, except as specifically provided in the policy; 

27. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic 

devices, or gynecomastia; except as specifically provided in the Benefits for 

Reconstructive Breast Surgery and Benefits for Treatment of Tumors and Leukemia; 

28. Treatment in a Government hospital for which the Insured is not charged, unless there is 

a legal obligation for the Insured Person to pay for such treatment; 

29. War or any act of war, declared or undeclared; or while in the armed forces of any country 

(a pro-rata premium will be refunded upon request for such period not covered); and 

30. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery 

for removal of excess skin or fat, and treatment of eating disorders such as bulimia and 

anorexia, except as specifically provided in the policy. Exception: benefits will be provided 

or the treatment of dehydration and electrolyte imbalance associated with eating 

disorders. 

General Provisions 

The Insurer will furnish the Insured the necessary forms for filing proof of loss. Claim forms 

may be obtained at the Company, P.O. Box 809025, Dallas, Texas 75380-9025. 

If the person making claim does not receive the necessary claim forms before the expiration 

of 15 days after first requesting such forms, the Insured Person shall be deemed to have 

complied with the requirements as to the proof of loss upon submitting to the Insured within 

90 days written proof covering the occurrence, character and extent of the loss for which 

claim is made. 

Written proof of loss must be submitted to the Company at P.O. Box 809025, Dallas, Texas 

75380-9025 within 90 days after expense is incurred, or as soon thereafter as reasonably 

possible. 

The Company, at its own expense, shall have the right and opportunity to examine the 

Insured as often as it may reasonably require and also may make an autopsy in case of 

death if not prohibited by law. Failure of an insured to present himself or herself for 

examination by a Physician when requested shall authorize the Company to: 1) withhold 

any payment of Covered Medical Expenses until such examination is performed and 

Physician's report received; and 2) deduct from any amounts otherwise payable hereunder 

any amount for which the Company has been obligated to pay a Physician retained by the 

Company to make an examination for which the insured failed to appear. Said deduction 

shall be made with the same force and effect as a Deductible herein defined. 

All benefits payable under the Policy will be paid upon receipt of due written proof of loss. 

All benefits are payable to the Insured or his designated beneficiary or beneficiaries or to 

his estate, except that if the person insured be a minor, such benefits may be made payable 

to his parents, guardian or other person actually supporting him. Subject to any written 

direction of the Insured, all or a portion of any benefits payable under the Policy may be paid 

directly to the Hospital, Physician or person rendering the service or treatment. 

No action shall be brought under the Policy prior to the expiration of 60 days after filing 

written proof of loss and no action may be brought after 3 years from the date within which 

proof of loss is required by the Policy. 

16

Scholastic Emergency Services: 

Global Emergency Medical Assistance 

If you are a student insured with this insurance plan, you are eligible for Scholastic 

Emergency Services (SES). The requirements to receive these services are as follows: 

International Students: You are eligible to receive SES worldwide, except in your home 

country. 

Domestic Students: You are eligible for SES when 100 miles or more away from your 

campus address and 100 miles or more away from your permanent home address or while 

participating in a Study Abroad program. 

SES includes Emergency Medical Evacuation and Return of Mortal Remains that meet the 

US State Department requirements. The Emergency Medical Evacuation services are not 

meant to be used in lieu of or replace local emergency services such as an ambulance 

requested through emergency 911 telephone assistance. All SES services must be 

arranged and provided by SES, Inc.; any services not arranged by SES, Inc. will not be 

considered for payment. 

Key Services include: 

* Medical Consultation, Evaluation and Referrals * Prescription Assistance 

* Foreign Hospital Admission Guarantee * Critical Care Monitoring 

* Emergency Medical Evacuation * Return of Mortal Remains 

* Medically Supervised Repatriation * Transportation to Join Patient 

* Emergency Counseling Services * Interpreter and Legal Referrals 

* Lost Luggage or Document Assistance 

* Care for Minor Children Left Unattended Due to a Medical Incident 

Please visit your school's insurance coverage page at www.uhcsr.com for the SES Global 

Emergency Assistance Services brochure which includes service descriptions and program 

exclusions and limitations. 

To access services please call: 

(877) 488-9833 Toll-free within the United States 

(609) 452-8570 Collect outside the United States 

Services are also accessible via e-mail at medservices@assistamerica.com. 

When calling the SES Operations Center, please be prepared to provide: 

1. Caller's name, telephone and (if possible) fax number, and relationship to the patient; 

2. Patient's name, age, sex, and Reference Number; 

3. Description of the patient's condition; 

4. Name, location, and telephone number of hospital, if applicable; 

5. Name and telephone number of the attending physician; and 

6. Information of where the physician can be immediately reached. 

SES is not travel or medical insurance but a service provider for emergency medical 

assistance services. All medical costs incurred should be submitted to your health plan and 

are subject to the policy limits of your health coverage. All assistance services must be 

arranged and provided by SES, Inc. Claims for reimbursement of services not provided by 

SES will not be accepted. Please refer to your SES brochure or Program Guide at 

www.uhcsr.com for additional information, including limitations and exclusions pertaining to 

the SES program. 

17

Claim Procedure 

In the event of Injury or Sickness, students should: 

1) Report at once to the Student Health Service or Infirmary for treatment, or when not 

in school, to the nearest Physician or Hospital. 

2) Secure a Company claim form from the Student Health Service or from the address 

below, fill out the form completely, attach all medical and hospital bills and mail to 

the address below. 

3) File claim within 30 days of Injury or first treatment for a Sickness. Bills must be 

received by the Company within 90 days of service. Bills submitted after one year 

will not be considered for payment except in the absence of legal capacity. 

The Plan is Underwritten by: 

UnitedHealthcare Insurance Company 

Submit all Claims or Inquiries to: 

UnitedHealthcare StudentResources 

P.O. Box 809025 

Dallas, Texas 75380-9025 

1-888-455-9402 

Sales/Marketing Service: 

UnitedHealthcare StudentResources 

805 Executive Center Drive West, Suite 220 

St. Petersburg, FL 33702 

Please keep this Certificate as a general summary of the insurance. The Master Policy on 

file at the school contains all of the provisions, limitations, exclusions and qualifications of 

your insurance benefits, some of which may not be included in this Certificate. 

The Master Policy is the contract and will govern and control payment of benefits. 

This Certificate is based on Policy 

2012-1806-1 

v2

[ 




ID# 

date of birth 

ACKNOWLEDGEMENT OF SUFFIELD ACADEMY MEDICAL PHILOSOPHY 


First Name Last Name Middle Name 

All Suffield students, both returning and new, must have an annual physical. A physical completed after March 1 of this year is acceptable for the upcoming 

school year. The completed form must be returned by the physician to the Health Center by July 15. If, for insurance constraints, you are unable to have a 

physical completed and returned by July 15, please notify the Health Center with the date of the physical. Should this date fall after the start of school, a note 

from the student’s primary care provider must be submitted to the Health Center stating that your daughter or son is cleared to participate in all school and 

athletic activities until the time of the physical. No student will be allowed to participate in the above without a physical or note. 

Prescriptions that are self-administered must be accompanied by written directions as to strength, dose, and duration by the student’s physician. Prescriptions 

for controlled substance drugs must be kept at the Health Center. All prescription medication kept on campus must be checked in through the 

Health Center. Medications that are to be kept in the dormitory will be noted in the medical record, and the Health Center will affix a label to the bottle 

identifying that this is safe to keep in the dorm and is documented. Medication not checked-in is considered contraband, and the matter will be transferred to the 

Dean of Students’ Office. A few medications (controlled and many psychotropics) are required to be kept in the Health Center and dispensed by the Health Center 

staff. All medications must be brought to the Health Center within 24 hours upon arrival or return to school. 

Any required immunizations that are not complete may be administered at the Health Center. 

Please check electronic signature approval box (or sign) below to acknowledge you understand Suffield’s medical philosophy and that you have completed all the 

medical forms to the best of your knowledge. 


Date 


[ 

FORM: MEDICAL / DUE: 07.15.12 

[

[ 




ID# 

date of birth 

PHYSICAL EXAMINATION RECORD FOR NEW STUDENTS 

Please be thorough. Omission of known health problems can jeopardize a student’s health care and well-being. A physical examination must be filed each year 

before a student may participate in any part of the school program. Physical must be done within one year. 


First Name last Name middle Name 

Blood pressure Pulse Asthma (preventative & emergency treatment) 

Height 

Weight 

Urinalysis 

sugar 

albumin 

micro 

Hemoglobin or hematocrit 

Prior medical/psychological conditions: 

Previous musculoskeletal injuries: 

Current medical/psychological conditions: 

Psychotherapy or counseling history: 

inches 

pounds 

Allergies (please list) 

Review of Systems Describe fully. Use additional sheet if needed. 

WNL 

Head, ears, nose, throat 

Hearing 

Respiratory 

Cardiovascular 

Gastrointestinal 

Hernia 

Eyes 

Genitourinary 

Musculoskeletal 

Metabolic/endocrine 

Neuropsychiatric 

Skin 

Any other conditions 

ABNL 

Medications to be continued at school 

(please list dose and schedule for each medication) 

My examination finds the student named above to be in good health, free from contagion, and physically and emotionally qualified for a full program of study and sports. 

Yes No If no, please explain: 

Print or type name and address of examining physician 

Name 

Phone Number 

Street City State Country Zip Code 

[ 

FORM: EXAMNEW / DUE: 07.15.12 

Physician’s Signature (required) 

[ 

Date

[ 



IMPORTANT INFORMATION ABOUT INFLUENZA AND INFLUENZA VACCINE 

What is Influenza (“Flu”)? 

Influenza (or “flu”) is a viral infection of the nose, throat, bronchial tubes and lungs that can make someone of any age ill. Usually the flu occurs in the United 

States from about November to April. If you get the flu, you usually have fever, chills, cough and soreness and aching in your back, arms and legs. Although 

most people are ill for only a few days, some persons have a much more serious illness and may need to go to the hospital. On average, thousands of people 

die each year in the United States from the flu or related complications. 

Who Should Get Influenza Vaccine? 

Because influenza is usually not life threatening in healthy individuals and most people recover fully, health officials emphasize the use of vaccine for 

persons who are at increased risk of complications from this illness. Persons who are at an increased risk of complications who should receive the influenza 

vaccine include: 

• children and adults with severe asthma, heart disease, diabetes, cystic fibrosis, kidney disease or anemia which has required 

regular visits to the doctor or hospitalization 

• children and adults who have a type of cancer or immunological disorder that lowers the body’s normal resistance to infections 

• children and teenagers on long-term treatment with aspirin who, if they catch the flu, may be at risk of getting Reye’s syndrome 

(a childhood disease that causes coma, liver damage and death) 

• residents of institutions housing patients of any age who have serious long-term health problems 

In addition, any person wishing to reduce their chances of getting the flu may choose to receive a flu shot, including: 

• students or other persons in schools and colleges, if a flu outbreak would cause major disruptions of school activities 

• persons traveling to the tropics at any time of the year or to countries to the south of the equator during April–September 

Influenza Vaccine 

Only a single flu shot is needed each season for persons 9 years of age and older, but children 8 years of age or younger may need a second shot after a month. 

Children less than 13 years old should be given only vaccine that has been chemically treated during manufacture (split virus) to reduce the chances of any side 

effects. Split-virus vaccines can also be used by adults. 

Possible Side Effects from the Vaccine 

Most people have no side effects from recent influenza vaccines. Flu shots are given by injection, usually into a muscle of the upper arm. This may cause 

soreness for a day or two at the injection site and occasionally may also cause a fever or achiness for one or two days. Unlike the 1976 swine flu vaccine, recent 

flu shots have not been clearly linked to the paralytic illness Guillain-Barr syndrome (GBS). In 1990-91 there may have been a small increase in GBS cases 

in vaccinated persons 18 to 64 years of age, but not in those under 18 or those over 65. This possible association with GBS was not as convincing as with 

the swine flu vaccine. Even if GBS was a true side effect, the very low estimated risk of getting GBS is less than that of getting severe influenza that would be 

prevented by the vaccine. As is the case with most drugs or vaccines, there is a possibility that allergic or more serious reaction, or even death, could occur with 

the flu shot. 

People who Should Check with a Doctor Before Taking Influenza Vaccine 

• Persons with an allergy to eggs that causes a dangerous reaction if they eat eggs and those who have had a serious reaction to previous 

influenza vaccination should consult a physician before receiving the vaccine. 

• Anyone who has ever been paralyzed with Guillain-Barr syndrome should seek advice from their doctor about special risks that might 

exist in their cases. 

• Women who are or might be pregnant should consult with their doctor. 

• Persons who are ill and have a fever should ask their doctor whether or not they should delay vaccination until the fever and other 

temporary symptoms have gone. 

Questions 

If you have any questions about influenza or influenza vaccination, please call us at the Health Center at 860-386-4503 or call your 

child’s doctor before signing this form. 

[ 

FORM: FLUVACCINE / DUE: 07.15.12

[ 




ID# 

date of birth 

Permission to Administer Influenza Vaccine 

Please sign and return this form, indicating your instructions. The cost of the vaccine is $25 

I have read the information sheet and I hereby authorize the Health Center staff to administer the influenza vaccine to: 



I authorize a $25 charge to my child’s debit card account. This charge is non-refundable if you sign this form as we order from this request. 


date 


[ 

FORM: FLUVACCINE / DUE: 07.15.12 

[

[ 

[ 




ID# 

date of birth 

IMMUNIZATION HISTORY FOR NEW STUDENTS 

CONNECTICUT STATE LAW requires the following 

DTaP/Td/Tdap at least 4 doses. Last dose must be given on/ after the 4th birthday. Students who start series at age 7 or older only need a total of 3 doses. 

Polio at least 3 doses. The last dose must be given on or after the 4th birthday. 

MMR 2 doses separated by at least 28 days, 1st dose on or after the 1st birthday. 

Hepatitis B 3 doses, last dose on/after 24 weeks of age. 

A Varicella (chickenpox) 1 dose on or after the 1st birthday or verification of disease. 


First Name Last Name middle Name 

Immunization History (please list all dates; boxes with an * must include a month/day/year date) 

DTaP/Td/Tdap 

TOPV/IPV (three doses; one dose after age 4) 

M.M.R 

or 

1. German Measles (Rubella) 

2. Measles 

3. Mumps 

Hepatitis B 

HIB 

1 2 3 4 5 6 

* * * * 

* * * 

* * 

* 

* 

* 

* 

* 

* * 

Varicella (chickenpox) 

(immunization or date of disease) 

Meningitis (recommended) 

Hepatitis A 

Gardisil (HPV) 

* 

* 

Tuberculin skin test (required for new students within the past year) 

Date Type results negative positive (if result is positive; chest x-ray required) 


Date 

[ 

FORM: IMMUNIZATION / DUE: 07.15.12

[ 




ID# 

date of birth 

PERMISSION FOR MEDICAL OR SURGICAL TREATMENT 

Treatment Waiver: This form must be signed by the student’s parent or legal guardian so that appropriate diagnosis and treatment may be promptly administered and so that no unnecessary 

delays will occur in case of a medical or surgical emergency. In the event of an emergency, every attempt will be made to contact and fully inform the parents or legal guardian. I hereby authorize the 

physician (M.D.) of Suffield Academy, Suffield, Connecticut, to procure and administer any care, medical or surgical, and any hospital care deemed necessary to restore health to my son or daughter. 

My son or daughter has my permission to self-administer any medication, ordered by the school physician or consulting physician, with the approval of the school nurse. The Headmaster or his 

designee may give permission for surgical or medical treatment for my son or daughter in the event I/we cannot be contacted. I authorize the school nurse or authorized faculty member to administer 

medications prescribed by the school physician or consulting physician. I further authorize that medical information be released to faculty and advisors on a need to know basis. 


First Name Last Name middle Name 

Student’s Social Security Number 

List Any Known Allergies 


Date 


PARENT or guardian CONTACT INFORMATION 

Name 

relationship to Student 


Home Phone 

Cell Phone 

Business Phone 

Email 

IN CASE the PARENT or guardian listed above cannot be reached, please contact 

Name 

relationship to Student 


Home Phone 

Cell Phone 

Business Phone 

Email 

MEDICAL INSURANCE INFORMATION 

Is a referral needed PCP Name Phone Fax 

Name of Insurance 

insurance Company’s Phone Number 

Address to mail claim form 

Name of Subscriber 

Subscriber’s Date of Birth 

Subscriber’s Place of Employment 

Insurance Identification Number 

Subscriber’s Social Security number 

[ 

PLEASE PROVIDE AN ENLARGED COPY OF THE FRONT AND BACK OF ALL INSURANCE CARDS 

FORM: TREATMENT / DUE: 07.15.12 

[

[ 

[ 




ID# 

date of birth 

AUTHORIZATION FOR THE ADMINISTRATION OF PRESCRIPTION MEDICINE 

BY SCHOOL PERSONNEL 

Any medication prescribed for a student must be reported to the Health Center. This form must be completed for all controlled substances, mood 

altering medications, and any other medication to be dispensed by school personnel. Connecticut State statute requires a physician’s or dentist’s written order 

and the parent’s/guardian’s authorization for a nurse to administer prescription medicine. 

Medications must be in pharmacy-prepared blister-pack containers and labeled with the student’s name, name of the drug, strength, dose, frequency, physician’s 

or dentist’s name, and date of the original prescription. The physician’s name and order must be the same on the authorization form and prescription bottle. 

All prescriptions may be included on this form. Photocopies of this form are acceptable. 

PHYSICIAN’S ORDER 



Diagnosis: 

I have evaluated and examined the student on (date) 

and plan to reassess the medication and treatment plan on (date) 

Drug: (name, dose, frequency and method of administration) 

Medication shall be administered from: (date) 

to: (date) 

Relevant side effects to be observed, if any: 

If there are side effects, give plan for management: 

Is this a controlled drug? Yes No If yes, DEA # 

type name and address of examining physician 

Name 

Phone Number 



Date 

[ 

FORM: PRESCRIPTION / DUE: 07.15.12

[ 

[ 




ID# 

date of birth 

Suffield Academy Concussion Testing 

Every student at Suffield Academy is required to participate in our ImPact Concussion testing program. The ImPACT test provides computerized neurocognitive 

assessment tools and services that are used by medical doctors, psychologists, athletic trainers, and other licensed healthcare professionals to assist them in 

determining an athlete’s ability to return to play after suffering a concussion. 

The test works by first taking a Baseline test to collect individual scores for each student. If a student were to get a head injury and exhibit concussive symptoms, 

they take the test again and their scores are compared to their baseline. Along with these scores and their current symptoms an evaluation and plan are 

made to help the student rest and heal accordingly. When the student is symptom free and has good ImPact scores compared to baseline, they begin our 

supervised return to play protocol. The return to play protocol consists of biking, jogging, non-contact, and contact sports, eventually clearing them to return 

to play their sport. 

We require that new students take their baseline tests at home before they come to school. Students will not be allowed to begin their 

athletic season until they have taken a baseline test. 

• Tests should be taken in a quiet room, away from distractions, with the computer plugged in to a power source. 

• Tests are taken using the Safari internet browser 

• An External Mouse must be used 

Impact Test Instructions 

1. Open broswer. 

2. Uncheck “Block Pop-Up Windows” in your browser. 

3. In the browser type in “https://www.impacttestonline.com/colleges” and hit the return button. 

4. In the pull down menu for “Please Select Your Organization” select Connecticut then hit the “Launch Baseline Test” button. 

5. When prompted, enter the following code: 58415F7283. After entering the code hit the “Launch Baseline Test” button. 

6. Read all instructions carefully. 

7. You will be asked what country you are from. If your country is not listed, pick the closest country geographically. 

8. When asked “what position you play” you can leave it blank unless you are a goalie in a sport you play. If that is the case, type in goalie. 

9. Read all the directions very carefully and take your time. 

10. The test will take approximately 30-35 minutes. 

The school will be notified upon your completion. 

[FORM IMPACTTEST DUE: 07.15.12

[ 




ID# 

date of birth 

PRIVATE MUSIC LESSON PROGRAM 

The Music Department of Suffield Academy offers private lessons at all levels for voice as well as instruments. Lessons are offered once each week and students 

are expected to practice regularly. A year-round commitment is important for substantial growth. 

In order to secure contracts with professional teachers, it is necessary for the Academy to commit financially to them in advance of the 

start of lessons. The cost of a full year of lessons is $925 (24 lessons), payable in advance to Suffield Academy. 

Students interested in scheduling private lessons should read the list of Student/Teacher Commitments below and fill in and sign the statement at the bottom, 

returning it with a check by September 10. 

STUDENT/TEACHER COMMITMENTS 

1. In the case of an unexcused absence from a lesson, the teacher will be paid and the lesson will not be rescheduled. In the case of two unexcused 

absences, the student’s parents and advisor will be notified and the possibility of discontinuing lessons discussed. If the number of 

these absences continues to four, parents and advisor will be notified again with the assumption that the student is not interested in 

lessons. The teacher will be paid for the lessons missed, and any balance of payment returned. 

2. In the case of an excused absence (i.e., sudden illness or emergency), the lesson will be rescheduled by the teacher if documentation is presented (a note 

provided by the school nurse or doctor). If the student is not able to come to school on the day of a lesson (due to illness), in addition to notifying the 

school, the teacher and the Music Department office must be notified directly and immediately. 

It is the responsibility of the student to reschedule the lesson with the teacher. If proper notification does not take place, the lesson will not be rescheduled. 

3. If a student cannot make a lesson for some other personal or school-related reason, and notifies the teacher at least 24 hours in advance, every effort will 

be made to reschedule the lesson. If the teacher cannot be reached directly, the Music Department must be notified at least 24 hours in advance. 

Please arrange for private music lessons at Suffield Academy for: 

Student Name 

Instrument 

Please send payment for $925.00 (payable in U.S. dollars to Suffield Academy) along with a copy of this form to Suffield Academy, Attn: Tom Gotwals 

185 North Main Street, Suffield, CT 06078. 

I understand and agree with the policies regarding private lessons. 


Date 


[ 

FORM: MUSIC / DUE: 07.15.12 

[

[ 

[ 




ID# 

date of birth 

Photo & Press Release Form 

I. Permission for Use of Name and Photographs 

The Marketing and Communications Office at Suffield Academy is responsible for the overall marketing of the school, which includes press about Suffield 

students. Toward that end, names and photographs of Suffield students are used on the school’s website, in the Academy’s alumni magazine, other school 

publications as needed, in regional and national magazines and newspapers, and in other forms of media, such as social media websites. In addition, the school 

creates certain administrative publications that include student names and addresses and parents’ names and email addresses. 

As parent or legal guardian of ____________________________________________________ I give permission to Suffield Academy to use the names, 

Student Name 

information and photographs of the aforementioned student for school advertising, marketing initiatives, administrative publications and other similar purposes 

that are intended to promote Suffield Academy. 

II. Press Release Information 

Please list the complete name and address of all of your local newspapers so we may share the good news about your child’s honor roll achievements, athletic 

awards, and Commencement. 


First Name last Name middle Name Year of Graduation 

Newspaper Name 

City 

State/Country 


City 

State/Country 


City 

State/Country 


date 

Check here if you do not want your child’s name released to local papers. 

By checking this box you indicate that you accept and acknowledge permissions to use name, information, 

and photographs of your child in Suffield publications, advertisements, websites, and newspapers. 

[ 

FORM: release DUE: 07.15.12

[ 

[ 




ID# 

date of birth 

Back to School Shipping In-Room Delivery (Order Estimate) 


First Name Last Name middle Name school 

Street City State Zip Code 

Country 

Home Phone 

Email 

Items to Ship 

Box Weight (lbs.) Box Dimensions (L x W x H) Declared Value Insurance 

1. 

2. 

3. 

4. 

5. 

Important Reminder: Please pack your boxes to meet packaging guidelines for UPS declared value coverage! 

• A minimum of 2” of cushioning around all sides of the box. 

• Box should be able to withstand a drop from 3 feet high 

• No shifting or movement of items within the box. 

• Fragile items should be bubble-wrapped and double boxed. 

Please plan ahead. We must receive your boxes by 8/31/2012 in order to provide In-Room delivery service. 

Please complete information above and fax or email to The UPS Store. We will respond with the your pricing quote based upon weights and dimensions provided. 

Phone: 860-871-7499 Fax: 860-871-8186 Email: store2195@theupsstore.com 

Price 

Signature 

Card # 

Exp 

Card Type 

Billing Zip 

Security Code 

[ 

FORM: SHIPPING / DUE: 07.15.12

[ 



E&R LAUNDRY SERVICE 

Dear Suffield Academy Parents: 

In the 2012-13 academic year, Suffield Academy and E&R—The Campus Laundry will once again partner to provide laundry services to all interested students. 

Anyone who has been in academia for a number of years comes to understand certain realities about student life; in particular that cleaning rooms and 

laundering clothes and bed sheets have become low priorities for many students, given their increasingly busy schedules. 

To help address this issue, E&R offers two especially efficient and practical programs—Look Sharp and Just the Basics. E&R has provided professional 

laundry services to over 100 preparatory schools, colleges and universities throughout the Northeast for over 50 years, and has designed its plans to allow 

students to make the most of their free time. Suffield Academy strongly recommends that you select one of these plans, which are currently available at 

discounted rates. 

To help you make the best selection for your student, the chart below compares the benefits of each of E&R’s service options: 

Features 

Wash/dry/fold laundry; neatly folded and right-side-out. 

Includes personal bed and bath linens (sheets, pillowcases, towels, face cloths, etc.) in addition to your clothing. 

Launderable, button-down dress shirts and blouses are pressed and returned on hangers. 

Gentle care washing, drying and pressing. * 

Skirts, dress pants and dress shorts, including khakis, returned pressed and on hangers. * 

Polo/Sport shirts returned pressed and on hangers. * 

Sweaters returned pressed and on hangers. * 

Professional dry cleaning and pressing. * 

Comforter and Blanket Cleaning Plan FREE: A $70 Value * 

*Service available for an additional fee; see the attached brochure for more details. 

Look 

Sharp 

◊ 

◊ 

◊ 

◊ 

◊ 

◊ 

◊ 

◊ 

◊ 

Just the 

Basics 

◊ 

◊ 

◊ 

* 

* 

* 

The Look Sharp and Just the Basics plans from E&R not only maximize your student’s available free time and promote a clean and healthy dorm room, they 

also help to reduce the school’s carbon footprint. Although the campus washers and dryers are relatively efficient, they cannot compare with the equipment at 

E&R’s central laundering facility in terms of gas, electricity, and water usage. 

E&R makes it easy to register your student via their online order form using the password CS70. You may also phone, fax, or mail your 

registration information back to them. Please see the enclosed registration form and promotional materials for details on how to order. Registration for any E&R 

service should be completed no later than August 15th, 2012 to receive E&R’s discounted rates. 

Over the years, E&R—The Campus Laundry has demonstrated a proven track record of providing reliable, professional and top quality 

service. We hope that you will consider subscribing to one of their service plans. 

P.S. If you have any questions, please contact E&R’s School Customer Service Office at 1-800-243-7789. Please retain this brochure for 

your record of E&R’s policies and procedures. 

[FORM LAUNDRY DUE: 08.15.12

Since 1921 Since 1921 

6078 • (860) 668-7315 • Fax (860) 668-2966 

Order 

Now 

Password 

CS70 

Increase your 

Academic Advantage 

Free Up 

With 

Time 

Our 

with 

“Look 

One 

Sharp” 

of Our Great 

Plan, 

Plans! 

You Also Get: 

“I had E&R in the 70s 

and now my son is 

using them.” 

– Facebook Dad quote 

86 % Water 

Savings 

“Peace of mind for a 

freshman and her 

parents! Thank you.” 

– Facebook Mom quote 

“BE NVIRONMENTALLY ESPONSIBLE” 

Register online at www.TheCampusLaundry.com using password CS7Ø 

Our “LOOK SHARP” Plan: $885* 

You’ll love it! 

– Wash/dry/fold laundry; neatly folded and right-side-out. 

– Includes personal bed and bath linens (sheets, pillowcases, 

towels, face cloths, etc.) in addition to your clothing. 

– Launderable, button-down dress shirts and blouses are 

pressed and returned on hangers. 

– Gentle care washing, drying and pressing 

– Skirts and dress pants, including khakis, returned pressed and 

on hangers 

– Polo/Sport shirts returned pressed and on hangers 

– Sweaters returned pressed and on hangers 

– Professional dry cleaning and pressing 

– Plus get our Comforter and Blanket Plan FREE: A $70 Value 

In addition to wash/dry/fold service, dry cleaning, gentle care 

processing and pressing are provided at NO ADDITIONAL CHARGE. * 

Our “JUST THE BASICS” Plan: $735* 

For the more casual student 

– Wash/dry/fold laundry; neatly folded and right-side-out. 

– Includes personal bed and bath linens (sheets, 

pillowcases, towels, face cloths, etc.) in addition to your 

clothing. 

– Launderable, button-down dress shirts and blouses are 

pressed and returned on hangers. 

To avoid additional charges, we strongly encourage 

you to consider our “Look Sharp” Plan.** 

* Plans are designed for individual use only. Sharing of plans between students constitutes immediate 

forfeiture of service with no refund provided. 

** Our policy is to return it to you clean, whenever we can, regardless of which plan you have 

purchased.With our “Just the Basics” Plan, a credit card is required to be on file for payment of 

additional monthly charges. Garment care labels often call for gentle care and/or dry cleaning. As 

a professional cleaner, we have an obligation to follow a garment’s care label. For example: We 

dry clean all sweaters; All fleece requires gentle care washing; Certain styles of Under Armour® 

type performance gear require gentle care. These items incur additional charges under our “Just 

the Basics” Plan. 

Our Most 

Popular Plan! 

64 % 80 % World-class, environmentally-aware 

student laundry and dry cleaning 

service. 

Should you require to Gas cancel these services for the FULL ACADEMIC ElectricityYEAR, you will receive a pro-rated refund, minus a $69 operations cancellation charge, provided that you submit a written cancellation request that is received no later than Oct. 15th, 2012. 

Savings 

Cancellation notices received after 

Savings 

that date, but before Jan. 2, 2013 will receive refunds for the second semester only, minus the $69 operations cancellation charge. There will be no refunds issued after Jan. 2, 2013. 

% 

A Healthy Lifestyle for Your Student 

- Students, and therefore their clothing, can be exposed to 

potentially infectious bacteria throughout their daily activities. 

- E&R has the exclusive distribution rights for BlockTeria, a fabric 

sanitizer that is added to each load we wash. 

- BlockTeria eliminates 99.999% of infectious contamination 

including MRSA-Staph. 

Gentle Care Processing vs. Dry Cleaning 

- Over 70% of items that we return to students on hangers are 

laundered and dried with a gentle care process, then pressed. 

- We launder all items that will get the same or better cleaning 

by using a gentle care laundry process vs. dry cleaning. 

Leaders in Sustainability 

86 % Water 

64 % Gas 

Savings 

86 % Water 

Savings 

64 % Students who use E&R generate the following utility savings with every load of 

laundry we do (savings based on independent Gas 

Savings study performed by TDK Engineering): 

Savings 

80 % Electricity 

Savings 

Order 

Now 

Password 

CS70 

Printable Order Form On Last Page 

Less than $5 

more per week! 

Suffield

Easy to Carry 

Separate 

Compartment for 

your Socks and 

Delicates 

Since 1921 

Introducing Our New, 

Duffle-Style Bag! 

Sewn in Hook 

Lets Bag Double 

as a Hamper 

www.Facebook.com/EandRLaundry 

EandRLaundry 

Local Business . Manchester, New Hampshire 

Keeps Clothes Neat and Secure 

Holds 25% More Than Our Old Style Bag! 

Robert, Groton Student 

E&R has made my life so much less stressful. I see people walking to do laundry 

all the time when I need to spend my time elsewhere. Thanks to E&R, I have an 

amazing luxury to spend my time the way I need to. All of my clothes are always in 

neat condition when returned which allows me to have a closet free of clutter while 

none of my time is wasted folding and ironing. Thank you, E&R! 

FAQs 

Can you tell me about your service? We have been providing laundry service to students for decades. If you wear it, we can take care of it. 

Please see the enclosed descriptions which will explain our plans in detail for you. 

My student has his own laundry bag. Do I have to use yours? Yes, you are only allowed to use the bag E&R provides. 

How do you know which bag belongs to my student? As you can see in the picture above, each bag is personalized with a printed label. In 

addition to the student’s name, our label also has a state-of-the-art bar code ID system allowing us to track the bag from pickup to delivery. 

If I’m signed up for the Comforter and Blanket Cleaning Plan, how do I fit that in my bag along with all of my clothes? Not to 

worry, we provide disposable, one-time-use bags for your comforter and blanket. You’ll get your first one when we give you your other laundry 

bag at the beginning of the year. We’ll then send a new disposable, one-time-use bag back to you along with your clean blanket or comforter so 

you can repeat the process the next time you want them cleaned. 

If I’m signed up for the Look Sharp or Just the Basics plan, will you also clean my personal sheets, pillow cases and towels? 

Yes, both plans include cleaning of your personal sheets, pillow cases and towels and they can go right in your laundry bag with the rest of your 

clothes. 

Should I label all my student’s clothes before I send them to you? No, we’ve got that covered too. We actually video tape all of your 

clothes when we check them in and again as we fold your laundry and put it back in your bag. Any clothes that are returned on a hanger get 

individually bar coded with either a permanent or temporary tag. This allows us to track all of your items on hangers when we deliver them back, 

just like we do with the laundry bag. 

Who is actually washing and dry cleaning my student’s clothes? All of the cleaning 

is performed in our state-of-the-art facility by personnel who have decades 

of experience in all areas of our operation. Because we control 100% of 

the work, you can count on us to be 100% responsible for making sure 

everything is done right. 

How do I sign up? Order online ! You can also register for service via 

phone, email, fax or postal mail. See the enclosed brochure for details on how 

to take advantage of whatever option works best for you. 

How will I know how to get started upon arrival at school? Once 

you have registered, we will notify you via email as to our bag distribution 

process at your particular school. We also staff a table on campus during 

student registration days to hand out laundry bags and answer questions 

about getting started. 

What if I have a question that isn’t answered in these FAQs 

or anywhere else on your brochure? Please be sure to contact our 

Customer Service Team if you require further information. Our contact 

information is on the Post-it Note to the right. 

Customer Service 

We’re here to help! 

As always, if you have questions that are 

not covered here, we are just a phone 

call or an email away. 

Warm Regards 

Cindy and Sarah 

Cindy Proctor and Sarah Robinson 

Tel: 800-243-7789 Ext. 713 and Ext. 714 

Email: Info@EandRCleaners.com 

About 

E&R -The Campus Laundry 

specializes in servicing the 

wash/dry/fold laundry… 

More 

1,125 

like this 

17 

talking about this 

11 

were here 

Scan to “Like” Us 

WIN GREAT PRIZES 

Like . Comment . January 16 at 4:32pm 

Shannon, Choate and Barnard College Mom 

Thanks E & R! You have been the saving grace for our family! We have one 

daughter at Choate and one at Barnard. Both love having your laundry service take 

that worry off of their minds. They say it is awesome to be able to send out a bag of 

dirty clothes and have clean ones “magically” reappear! We love E&R!! 

Like . Comment . January 12 at 6:47pm 

LA, Salisbury Mom 

E&R Laundry service is by far the best service being offered to students!! Not 

only is it convenient but the service my son receives has been top notch. The staff 

have been excellent to work with and being from another country it gives me piece 

of mind knowing that my son never has to worry about his clothing. Thank you to 

everyone at E&R. 

A very grateful Salisbury Mom 

Like . Comment . January 12 at 4:44pm 

Wendy, Colby College Mom Mom 

My son Nicholas just doesn’t have time in his busy schedule for laundry. Thank 

heavens for E&R. I’m really not sure what he would do or how he would manage 

without you. 

Like . Comment . January 12 at 12:01pm 

Debra, Berkshire Mom 

2 TEENAGE BOYS, 2 DORM ROOMS, 6 JV AND VARSITY SPORTS, 12 

CLASSES PLUS CHORUS & GREENSLEEVES! HOW MANY KHAKIS, DRESS 

SHIRTS, SWEATERS AND BLAZERS DOES IT TAKE TO GET THRU THE 

YEAR…THANK HEAVENS FOR E & R LAUNDRY! YOU MAKE MIRACLES 

EVERY DAY. THANK YOU, BERKSHIRE SCHOOL MOM! 


Cole, Suffield Student 

E&R laundry has been a HUGE blessing helping me get through the school year 

at Suffield Academy. I don’t know what I would do without you! Thank you! 


Leslie, Wesleyan University Mom Mom 

My son goes to school 15 hours away from home and this service has been 

Great! Definitely recommend your service! 


WIN FREE SERVICE 

WIN COOL SWAG 

Printable Order Form On Last Page

06078 • (860) 668-7315 • Fax (860) 668-2966 

Since 1921 Since 1921 


"Look Sharp" 

Our Most 

Popular 

Plan! 

Less than $5 

more per 

$885 

( Order All pricing now is and for save! the full $920 academic after 8/15/12 year. ) 

( # 650) week! 

( # 652) 

In addition to wash/dry/fold service, dry 

cleaning, gentle care processing and pressing 

are provided at NO ADDITIONAL CHARGE. 

"Just The Basics" 

$735 

( Order All pricing now and is for save! the full $770 academic after 8/15/12 year. ) 

A credit card is required to be on file for the billing of incidental charges: 

Card # 

exp. date CCV# * 

ADDITIONAL PLANS 

"Fresh" Comforter & Blanket Cleaning - Free 

( We'll clean your own comforter and/or blankets up to five 

# 655) 

times during the school year. (Free with “Look Sharp” plan) 

"Fresh" Bed & Bath Linen Rental Plan - $135 

( Four (4) Flat sheets, two (2) pillow cases, and six (6) large 

# 654) 

(24" x 48") top quality bath towels to use and send for 

cleaning as needed. 

"Fresh" Towel Rental Plan - $75 

( Four (4) large (24" x 48") top quality bath towels to use 

# 653) 

and send for cleaning as needed. 

NAME OF CARDHOLDER (Please Print) 

SIGNATURE 

ADDITIONAL PLANS 

( # 655) 

( # 654) 

( # 653) 

"Fresh" Comforter & Blanket Cleaning - $70 

"Fresh" Bed & Bath Linen Rental Plan - $135 

"Fresh" Towel Rental Plan - $75 

PLEASE PRINT Year of Graduation? Gender? Male Female (Check one) 

STUDENT NAME (AS REGISTERED AT SCHOOL) FIRST/LAST 

STUDENT CELL PHONE 

STUDENT EMAIL 

CELL PHONE CARRIER 

PARENT OR GUARDIAN (PLEASE PRINT) FIRST/LAST PARENT PHONE PARENT EMAIIL 

billing ADDRESS (STREET) 

CITY STATE ZIP COUNTRY 

Did this student use an E&R service at Suffield academy in the 2011-2012 academic year? YES NO (Check one) 

Payment Method: n Same as Above n MASTERCARD n VISA n DISCOVER -or- n Check Make checks payable to E&R Cleaners 

NAME OF CARDHOLDER (Please Print) 

SIGNATURE 

- - - 

CARD# exp. date CCV# ** 

For Office Use Only Bag# CS 

** Your CCV# is the last three digits of the number in the signature section of your card 


Phone Orders: 800-243-7789 inside the U.S.; Mail Registration Form to: E&R Laundry and Dry Cleaners 

603-627-7661 outside the U.S. 

School Department 

Fax Orders: 603-627-7644 

80 Ross Avenue 

Manchester, NH 03103-9962 

Should you require to cancel these services for the FULL ACADEMIC YEAR, you will receive a pro-rated refund, minus a $69 operations cancellation charge, provided that you submit a written 

cancellation request that is received no later than Oct. 15th, 2012. Cancellation notices received after that date, but before Jan. 2, 2013 will receive refunds for the second semester only, minus 

the $69 operations cancellation charge. There will be no refunds issued after Jan. 2, 2013. 

Register by 

August 15th 

and Save!



JULIE’S LAUNDRY SERVICE 

919 Enfield Street (Rt. 5) Enfield, CT 06082 phone (860) 745-4522 cell (860) 394-8051 

Please return this form to the address above or by email. jpoonlai@yahoo.com 

Suffield Academy Students Individual Laundry Account Sign-up Form 2012-2013 School Year (9/6/2012-5/30/2013) 

Student Name: ______________________________________________ Billing Person: ______________________________________________ 

Dorm: ____________________________________________________ Address: ___________________________________________________ 

Grade: ____________________________________________________ __________________________________________________________ 

Phone: ___________________________________________________ Phone: _________________email:_______________________________ 

Email: ____________________________________________________ [ ] Check enclosed. $__________________________________________ 

Please make checks payable to Julie’s Laundromat & Cleaners 

[ ] Discover, Visa & Mastercard add 4% service charge. 

#______________________________________Expires: _____________ 

There are 5 plans to choose from: 

Each plan includes 2 Laundry Bags and 2 Garment Bags, except Plan #5. 

The bags are yours to keep. There is no extra charge if you take them home in May. 

[ ] Plan #1 $685.00 

• Wash-Dry-Fold and Hang. 

[ ] Plan #2 $825.00 


• Wash and Press dress shirts, blouses, slacks, skirts, and dresses. 

[ ] Plan #3 $375.00 Minimum Charge 

• Wash-Dry-Fold by the pound. $1.00/lb, minimum 12 lb. 

• Pressing, dry cleaning, leather cleaning and sewing services are charged itemized. 

• A statement will be sent home after the school year ends if the amount used is over $375.00. 

[ ] Plan #4 $885.00 


• DRY CLEAN & Wash and Press dress shirts, blouses, slacks, skirts, dresses, suit jackets, ties and sweaters. 

[ ] Plan #5 $300.00 (Must sign up early & must sign up in conjunction with any of the above plans) 

[ ] Renewal $50.00 (Your Linen Package stored for the summer, cleaned and delivered to your dorm upon your arrival in Sept.) 

• Linen Rental - Package includes: New 2 Blankets, 2 Sheet Sets, 4 Towel Sets. 

• Wash, Dry & Fold with your laundry. This set of linen is purchase for your use only for the academic year. 

• For your convenience, we pre-wash the new linens so that you can use them immediately in your dorm. 

√ Sign up by August 15, 2012 and your welcome package will be ready for you at registration. 

√ First pick up service is on Sept. 6th, 2012 around 11:30am at the Student Union Locker Room. 

√ DELIVERY DAYS are BOTH MONDAYS & THURSDAYS. 

When you drop off laundry on Mondays your clean laundry will be returned to your dorm on Thursdays. 

When you drop off laundry on Thursdays your clean laundry will be returned to your dorm on Mondays. 

√ We do each student’s laundry individually and with care. Sorry, we do not hand wash. We are not responsible for any lost articles, garments that 

run or garments that do not hold up in the cleaning process. 

√ For best results: Initial your garments, turn garments right side out, unbutton shirts, empty pockets, and don’t mix in wet 

items with your laundry. For quick returns: Separate dry cleaning from laundry. 

√ Refund policy for early termination of laundry Plan 1, 2, and 4 are to convert into Plan 3. You will be charged $375.00 or what you used plus a 

$50.00 service fee, which ever is more. No refunds for plan #5. No refunds after January 1st, 2013. 

Thank you for choosing Julie’s; we have served Suffield Academy students since 1991 with quality service and care. We are proud to 

celebrate 27 years in business. We look forward to serving your laundry needs for the coming academic year.

Dear Sufüeld Academy Parents and Students: 

First we want to give a very special thanlis to 

Suffreld Academy who have supported us since lÐ1. 

Thank you for giving us the opportunity to serve all 

yoru laundry needs. We appreciate and value ou¡ 

Julie's Laundromat & Cleaners 

Business Hours: 

Mondays to Saturdays 7:30am to 9:00pm 

Sundays 7:30am to 7:00pm 

Closed on New Year Day, Easter Sunday, Memorial Day, 

Independence Day, Thanksgiving Day and Christmas Day. 

relationship wittr Suffield Academy and we are proud 

to celebrate 27 yearc in business since 1985. 

In thinking GREEN, the fabric laundry & 

garment bags are a big help to reduce plastic bag 

waste. Therefore, we will continue to use them this 

yeaf. 

Our bags are color coded to your dorm. If 

you don't have your dorm assignments yet, you should 

stilt sigr up early and we will get the dorm info from 

Suffreld Academy to prepare your welcome package. 

Ncrv spccial fcaturc fnr Pl¿n #5 Lincn 

{ 

Rent¿ls. The linen rental service is $300 for initial 

sign ups with all new linens washed and ready to 

use. Each annual renewal is $50.00 which includes 

storage for the summer, cleaned and delivered to your 

dorm the following school year. This plan must be 

used in oonjunction with Plan #1.#2, #3 or #4. This 

plan will help lighten your load on move-in day. 

Please read through and keep this brochu¡e 

for future reference as it contains information of our 

services. Ifyou still have questions, please don't 

hesitate to contact us by phone or email. 

We hope you have a wonderful surnrner, We 

look fonvard to serving all your laundry needs. See 

you at registration. 

Sincerely, 

Julie and Staff 

Directions from Suffreld Acaderny: 

Come visit us if you are in the areo. 

1 : Staf out going NORTH on N IVÍAIN ST / CT-75 toward 

SILES RD.0.8miles 

2: Tum RIGIIT onto MAPLETON AVE / CT-190. 0.5 miles 

3: TUM SLIGFIT RIGHT ONIO THOMPSONVILLE RD / 

CT-190. 1.1miles 

4: Tum RIGIIT onto EAST ST N / CT-159 / CT-190. 0.6 miles 

5: Turn LEFT onto CT-190. 0.6 miles 

6: Take üreramp towanlUS-5 /ENFIELD. 0.1 miles 

7: Tu¡n SLIGHT LEFT onto FREW TER. 0.1 miltx 

8: TumLEFT onto ENFIEI-,D ST /US-5. 0.4 miles 

9: Arrive at Julie's Laundromat & Cleaners, 

919 Enfrcld St, Enfield, CT 06082, US 

Total Est. Time: l0 minutes 

Total Est. Distance: 4 65 miles

Su eld Academy Students Laundry Plans 

Julie's Laundry Service at Suflield Academy since 1991 

Julie's 5 Laundry Service Plans: 

Suffield Academy 2012-2013 School Year 

Sign up by August l5r20l2 andyou will 

receive your welcome package of 2 fabric laundry 

and garmenL bags at regislration. These 4 bags are 

yours to keep at the end ofthe year. 

Julie's Cleaners wil[ be at registrationon9/4,9/6 

&.917/2012 for a meet & greet, and to answer any 

çestions or concerns you may have. 

We offer DOUBLE THE SERVICE with pick 

ups in the Student ion Locker Room and drop 

offs in your dorm on both Mondays and 

Thursdays. First day of service will begin on 

Thursday 9/6/12 @11:30am. This is a special 

start date for the Varsity Candidates and 

Proctors. 

We tn¡st an honor system. If you miss a pick up, 

we understand you will have more laundry the 

next time. 

We do each student's laundry individually and 

with care. Sorry we do not hand wash. We do not 

take responsibilþ for any lost articles, garments 

that nur or do not hold up in the cleaning process. 

For best results: Initial your gaments. turn all 

garments right side out, unbutton shirts, empty 

pockets and don't mix in wet items with your 

laundry. 

We offer free minor sewing sen'ice and special 

laundry needs. Just include insfuctions with your 

phone number and we will do our best for you. 

Julie's st¿ffis very honest. Over the years we have 

found and retumed many wallets, keys, MP3s, cell 

phones, credit cards, money and other valuables to 

their owners. 

Please THINK GREEN by using both laurdry 

& garment bags every time. We also encourage the 

re-use of good hangers. Together we can generate 

less trash for our environment. 

Extra charge items not included in your plan will be 

charged to your school account or invoiced home at 

thc cnd ofthc school ycar. 

Refund policy for early termination of laundry 

Plans #1, #2, &.#4 is ûo convert to Plan #3. You 

will be chargcd $375.00 or your itcmize usage plus 

a $50.00 service fee which ever is more. No 

refunds for Plan #5. There are no refirnds after 

January lst,2013. 

Got laundry? 

Julie's Laundromat & Cleaners can help! 

From Sept. 6th, 2012 to May 30th, 2013 

Plan #1 S685.00 (2 laundry & 2 garment bags) 

o Vy'ash-Dry-Fold and Hang. 

Plan #2 $825.00 (2 laundry & 2 garment bags) 

o Vy'ash-Dry-Fold and Hang. 

. Wash and Press dress shi¡ts, blouses, slacks, ski¡ts and 

dresses. 

Plan #3 $375.00 Minimum Charge 

(2 lamdry & 2 garment bags) 

¡ Wash-Dry-Fold; $1.00/lb, minimum l2lbs. 

o F'ressing, dry cleaning, leather cleaning and sewing 

services are charged itemized. A statement will be sent 

home after the school year ends if the amount used is 

over $375.00. 

Plan #4 $885.00 (2 laurdry & 2 garment bags) 

o Wash-Dry-Fold and Hang. 

o Wash and Press dress shirts, blouses, slacks, skirts, and 

dresses. 

o Dry Cleanjackets, ties, sweaters, slacks, skirts & dresses. 

Plan #5 5300.00 Must sign up early and in conjunction 

with any one ofthe above laundry plans. 

o Linen Rental Sen¡ice (Package includes: All new 2 

Blankets, 2 sheets sets, 4 towel sets. These linens are 

assigned to ¡rou for the academic year. For your 

convenience, these items will be washed and ready for 

you to use upon your a¡rival. 

o Wash, Dry and Fold with your launclry. 

o Annual Renewal $50.00 

The above plans are priced for ONE studentfs 

normal usage only. NO Limits per pick up for 

your convenience but we appreciate your 

understanding and cooperation to this honor 

system. Together we can keep prices down. 

Thank you!

[ 




ID# 

date of birth 

June 5, 2012 

To: 

New International Students and Parents 

From: 

Charles Cahn III, Headmaster 

Welcome to Suffield! 

I am writing to tell you about plans for arrival and orientation at Suffield this fall. We invite all new international students to join us a day early for a special 

orientation program beginning on Thursday, September 6. This includes all students who reside outside of the continental U.S., regardless of nationality, as 

well as students residing in the U.S. who are not U.S. citizens. Our international families have special needs and interests at Suffield, and we have designed 

this program to address these issues. 

The orientation schedule below outlines the plans for Thursday, September 6, and Friday, September 7. Complete details for the orientation will be available 

at registration. I am looking forward to greeting you in September. 

Date Time Event 

Thursday, 

September 6 9:30-11:00 A.M. Registration Centurion Hall 

6:00-9:00 P.M. Orientation for Students S. Kent Legare Library 

Friday, 

September 7 Morning Orientation 

Review of Rules 

Placement Testing 

[ 

FORM XX DUE: 07.15.12 

[

Order now and save! $920 after 8/15/12 - Suffield Academy

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?