belmont hill school visiting student permission, waiver and medical ...

BELMONT HILL SCHOOL
VISITING STUDENT PERMISSION, WAIVER AND MEDICAL FORMS
Your son has elected to participate in an exchange program with Belmont Hill School. This
packet contains the following forms:
• Parent Questionnaire
• Parental Consent and Indemnity
• Medical Treatment Consent and Emergency Information
• Concussion Letter
• Meningococcal Disease and Vaccination Information and Waiver
• Sudden Cardiac Arrest Risk Assessment
• Physician’s Report
• Medical Information Summary
Please complete these forms as directed and return them to Cheryl Wolf, Global Education
Coordinator, by scanning and emailing them to wolf@belmonthill.org or by fax to 617-484-
4688.

BOY’S NAME
PLEASE PRINT NAME IN FULL
BELMONT HILL SCHOOL
PARENTAL CONSENT AND INDEMNITY
PLEASE COMPLETE AND SIGN BELOW
MOTHER/GUARDIAN
PLEASE PRINT NAME IN FULL
FATHER/GUARDIAN
PLEASE PRINT NAME IN FULL
I/We do hereby agree and consent to my/our son/ward, “the child,” participating in any educational, physical or
extra-curricular activities (“activities is deemed to include transportation to and from the activities organized by or
on behalf of Belmont Hill School (“the School”) throughout the course of the child’s enrollment at the school.
FURTHER and in consideration of the School agreeing to the child’s enrollment and allow the child to participate in
activities, I/We hereby:
1. Authorize the School’s teachers, instructors and agents to take whatever disciplinary action they deem
necessary to ensure the safety, well-being and successful conduct of the child in the activities.
2. Authorize the School’s teachers, instructors and agents to obtain any medical or dental treatment or
ambulance transport which they deem necessary for the child and agree to pay all expenses incurred on
behalf of the child. I/We further authorize qualified medical practitioners to take whatever medical action
they consider necessary for the child’s welfare and well-being.
3. Submit on the enclosed medical forms any details which may assist the School to meet the needs of the
child including any condition that may prevent the child from participating in the School’s activities.
4. Recognize that it is my/our responsibility to keep the School informed of any changes which may occur to
the child’s medical or physical condition.
5. Agree to:
a. Disclaim all my/our legal rights and remedies against the School, its teachers and agents, for all
costs, damages or other expenditures incurred by them or on their behalf arising from or in
connection with any claim or demand made by or on behalf of any child or any third party as a
result of any injury, loss or damage (including property damage) where in all circumstances the
staff have not been negligent.
b. Indemnify and hold harmless the School, its teachers and agents, for all costs, damages or other
expenditures incurred by them or on their behalf arising from or in connection with any claim or
demand made by or on behalf of the child or any third party as a result of any injury, loss or
damage (including property damage) where in all circumstances the staff have not been negligent.
Dated this day of , 20 .
Signature
Signature
[Signature of Mother/Guardian]
[Signature of Father/Guardian]
Witness
Witness

BELMONT HILL SCHOOL
MEDICAL TREATMENT CONSENT & EMERGENCY INFORMATION
This form is an emergency information and consent statement that must be completed and signed by a
parent or guardian. A student will not be permitted to participate in athletics or start classes until all
forms are completed and returned to Belmont Hill School.
Student’s Name
Home Address
Last First M.
Street City State Zip
EMERGENCY CONTACTS
Parent#1 Parent #2
Date of Birth ____/____/____
Home Phone (____) Home Phone (____)
Work Phone (____) Work Phone (____)
Cell Phone (____) Cell Phone (____)
Alternate Emergency Contact
Relation Home Phone: (____) Work Phone: (____)
PRIMARY CARE PHYSICIAN
Physician Name
Phone (____)
Address
EMERGENCY MEDICAL INFORMATION
Date of Last Tetanus/Diphtheria (Td or Tdap) ____/____/
(from Physician’s Exam)
Does your son require: Contact Lenses Yes ___ No___ EpiPen Yes ___ No___
Allergies (to food or medication)
Regular medications
Medical conditions/concerns relevant to School attendance or trips away from School:
INSURANCE INFORMATION
Insurance
Policy ID#
Policy Holder
Phone Number (____)

BELMONT HILL SCHOOL
MEDICAL TREATMENT and EMERGENCY CONSENT
Student’s Name
Date of Birth ____/____/
I hereby give consent for Belmont Hill School Health Care Providers (the School Nurse and Athletic
Trainer), or other Health Care Providers considered appropriate by them, to carry out accepted
procedures for diagnosis, minor medical treatment, minor surgical treatment, and in-school counseling
for my son/ward - unless I specify otherwise in the comments space provided below.
In the event of emergency in which time is an important factor and the School is unable to contact me or
an alternate Emergency Contact, I authorize School Health Care Providers, School Officials, or during
athletic competitions, Coaches, or during field trips, Teachers in charge, to exercise their best
judgement, and hereby authorize them to approve necessary and urgent medical or surgical treatment
and/or hospitalization in the interest of my son’s/ward’s welfare.
I also give permission for medical information provided by me to the School to be released to School
Health Care Providers, and at their discretion to School Faculty on a limited need-to-know basis, as well
as to other appropriate Health Care Providers who may need this information in order to treat my
son/ward in a medical emergency.
Comments:
Date ____/____/____
Signature of Parent or Guardian
School Health Care Provider Notes

Dear Parent/Guardian,
Belmont Hill School is currently implementing an innovative program for our student-athletes.
This program will assist your physician and the schools athletic trainers in evaluating and treating
head injuries (e.g., concussion). In order to better manage concussions sustained by our studentathletes,
we have acquired a software tool called ImPACT (Immediate Post Concussion
Assessment and Cognitive Testing). ImPACT is a computerized exam utilized in many
professional, collegiate, and high school sports programs across the country to successfully
diagnose and manage concussions. If an athlete is believed to have suffered a head injury during
competition, ImPACT helps to objectively quantify the severity of head injury and when the
injury has recovered to baseline.
The computerized exam is given to athletes before the beginning of school to provide a baseline
evaluation of all students. This non-invasive test is set up in “video-game” type format and takes
about 30-40 minutes to complete. It is simple, and actually many athletes enjoy the challenge of
taking the test. Essentially, the ImPACT test is a preseason physical of the brain. It tracks
information such as memory, reaction time, speed, and concentration. It, however, is not an IQ
test.
If a concussion is suspected, the athlete will be required to re-take the test. Both the baseline and
post-injury test data can be given to your personal physician, neurologist or neuropsychologist to
help evaluate the injury. The test data will enable these health professionals to determine when
return-to-play is appropriate and safe for the injured athlete. If an injury of this nature occurs to
your child, you will be contacted with all the details. If a concussive injury occurs in athletics
outside the school, your child could be tested as soon as they are back in school, if the injury
occurs during the school year.
I wish to stress that the ImPACT testing procedures are non-invasive, and they pose no risks to
your student-athlete. Currently all baseline testing can be done online from any computer with an
internet connection, and post injury testing is done with the schools AT’s.
We ask that all new incoming students take this test prior to the beginning of the school
year. Your son would go online and type in the following link:
https://www.impacttestonline.com/schools (type this link in). Please use the following code to
launch the baseline test WP2TQV2UC8
This link will bring you to Impacts site where you will be able to launch the baseline test. The
student would need to select his state and follow the directions. On a succeeding page there will
be a drop down menu where they will highlight Belmont Hill School and all data will be stored to
be accessed only by the schools medical personnel. If you have any questions or concerns,
please contact me at either of the following:
Email: dohertye@belmont-hill.org
Phone (617) 993-5297
Regards,
Ed Doherty, ATC

Information about Meningococcal Disease and Vaccination
and
Waiver for Students at Residential Schools and Colleges
Legislation has been enacted in Massachusetts requiring all new students at residential schools (e.g., boarding
schools) with grades 9-12 and postsecondary institutions (e.g., colleges) that provide or license housing to:
1. receive meningococcal vaccine prior to the beginning of classes; or
2. fall within one of the exemptions in the law, which are discussed below.
The law provides an exemption for students signing a waiver that reviews the dangers of meningococcal disease
and indicates that the vaccination has been declined. To qualify for this exemption, you are required to review
the information below and sign the waiver at the end of this document. Please note, if a student is under 18
years of age, a parent or legal guardian must be given a copy of this document and must sign the waiver.
What is meningococcal disease
Meningococcal disease is caused by infection with bacteria called Neisseria meningitidis. These bacteria can
infect the tissue that surrounds the brain and spinal cord called the “meninges” and cause meningitis, or they can
infect the blood or other body organs. In the United States, about 2,600 people each year get meningococcal
disease and 10-15% die despite receiving antibiotic treatment. Of those who survive, about 10% may lose limbs,
become deaf, have seizures or strokes, or have other problems with their nervous system.
How is meningococcal disease spread
These bacteria are passed from person-to-person through saliva (spit). You must be in close contact with an
infected person’s saliva in order for the bacteria to spread. Close contact includes activities such as kissing,
sneezing, coughing, sharing water bottles, sharing eating/drinking utensils or sharing cigarettes with someone
who is infected.
Who is at most risk for getting meningococcal disease
People who travel to certain parts of the world where the disease is very common are at risk, as are military
recruits who live in close quarters. Children and adults with damaged or removed spleens or an inherited
disorder called “terminal complement component deficiency” are at higher risk. People who live in settings such
as college dormitories are also at greater risk of infection.
Are some students in college and secondary schools at risk for meningococcal disease
College freshmen living in residence halls or dormitories are at an increased risk for meningococcal disease as
compared to individuals of the same age not attending college. The setting, combined with risk behaviors (such
as alcohol consumption, exposure to cigarette smoke, sharing food or beverages, and activities involving the
exchange of saliva), may be what puts college students at a greater risk for infection. There is insufficient
information about whether new students in other congregate living situations (e.g., residential schools) may also
be at increased risk for meningococcal disease. But, the similarity in their environments and some behaviors
may increase their risk.
The risk of meningococcal disease for other college students, in particular older students and students who do
not live in congregate housing, is not increased. However, meningococcal vaccine is a safe and efficacious way
to reduce their risk of contracting this disease.
Is there a vaccine against meningococcal disease
Yes, there are currently 2 vaccines available that protect against 4 of the most common of the 13 serogroups
(subgroups) of N. meningitidis that cause serious disease. Meningococcal polysaccharide vaccine is approved
for use in those 2 years of age and older. In January 2005, a new type of meningococcal vaccine was licensed,
called meningococcal conjugate vaccine, and is currently only approved for use in those 11- 55 years of age.
Both types of meningococcal vaccines are acceptable for college students and residential school students 11
years of age and older. For those younger than 11 years of age, meningococcal polysaccharide vaccine is the
only licensed vaccine.
Both of the vaccines provide protection against four serogroups of the bacteria, called groups A, C, Y and W-
135. These four serogroups account for approximately two-thirds of the cases that occur in the U.S. each year.
Most of the remaining one-third of the cases are caused by serogroup B, which is not contained in the vaccine.
Protection from immunization with the meningococcal polysaccharide vaccine is not lifelong; it lasts about 3 to 5
years in healthy adults (some people may be protected longer.) The meningococcal conjugate vaccine is
expected to help decrease disease transmission and provide more long-term protection.

Is the meningococcal vaccine safe
A vaccine, like any medicine, is capable of causing serious problems such as severe allergic reactions. The risks
associated with receiving the vaccine are much less significant than the risks that would arise in a case of
meningococcal disease. Getting meningococcal vaccine is much safer than getting the disease. Some people
who get meningococcal vaccine have mild side effects, such as redness or pain where the shot was given.
These symptoms usually last for 1-2 days. A small percentage of people who receive the vaccine develop a
fever. The vaccine can be given to pregnant women.
Is it mandatory for students to receive meningococcal vaccine prior to entering secondary schools or
colleges that provide or license housing
Massachusetts law (MGL Ch. 76, s.15D)) requires new students at residential schools (e.g., boarding schools)
with grades 9-12 and new full- and part-time, undergraduate and graduate students in degree-granting programs
at postsecondary institutions (e.g., colleges) that provide or license housing to receive meningococcal vaccine.
At affected institutions, the new requirements apply to all new students, regardless of grade (including grades
pre-K through 8), year of study, and whether or not they reside in school- or campus-related housing. Beginning
in August 2005, all new students at these institutions must provide documentation of having received
meningococcal vaccine (within the last 5 years) at least 2 weeks prior to the beginning of classes, unless they
qualify for one of the exemptions allowed by the law.
Students may begin classes without a certificate of immunization against meningococcal disease if: 1) the
student has a letter from a physician stating that there is a medical reason why he/she can’t receive the vaccine;
2) the student (or the student’s parent or legal guardian, if the student is a minor) presents a statement in writing
that such vaccination is against his/her sincere religious belief; or 3) the student (or the student’s parent or legal
guardian, if the student is a minor) signs the waiver below stating that the student has received information about
the dangers of meningococcal disease, reviewed the information provided and elected to decline the vaccine.
Consideration is being given to amending the law regarding the students to be covered by the requirement.
When and if the law is amended, regulations regarding meningococcal vaccination may change.
Where can a student get vaccinated
Students and their parents should contact their healthcare provider and make an appointment to discuss
meningococcal disease, the benefits and risks of vaccination, and the availability of this vaccine. Schools and
college health services are not required to provide you with this vaccine.
Where can I get more information
• Your healthcare provider
• The Massachusetts Department of Public Health, Division of Epidemiology and Immunization at (617)
983-6800 or www.mass.gov/dph
• Your local health department (listed in the phone book under government)
________________________________________________________________
Waiver for Meningococcal Vaccination Requirement
I have received and reviewed the information provided on the risks of meningococcal disease and the risks and
benefits of meningococcal vaccine. I understand that Massachusetts’ law requires students enrolled at
secondary schools, colleges and universities that provide or license housing to receive meningococcal
vaccinations, unless the students provide a signed waiver of the vaccination or otherwise qualify for one of the
exemptions specified in the law.
After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of
meningococcal vaccine.
Student Name:
Student ID or SSN:
Date of Birth:
Today’s Date:
Signature:
(Student or parent/legal guardian, if student is under 18 years of age)
Provided by:
Massachusetts Department of Public Health / Division of Epidemiology and Immunization / 617-983-6800
MDPH Meningococcal Information and Waiver Form March 2005

BELMONT HILL SCHOOL
SUDDEN CARDIAC ARREST RISK ASSESSMENT
STUDENT’S NAME: ____________________________ FORM: ____
Patient history questions YES NO
Has your child ever fainted or “passed out” DURING exercise,
emotional upset or after being startled
Has your child ever fainted or “passed out” AFTER exercise
Has your child had extreme fatigue associated with exercise
(different than other children)
Has your child ever had unusual or extreme shortness of breath
during exercise
Has your child ever had discomfort, pain or pressure in his chest
during exercise
Has your child ever been diagnosed with an unexplained seizure
disorder
Family history questions YES NO
Are there any family members who had an unexpected,
unexplained death before age 50 (including sudden infant death
syndrome, car accident, drowning, etc)
Are there any family members who died from, or been diagnosed
with heart problems before age 50
Are there any family members who have had unexplained fainting
or seizures
If you have answered “yes” to any of the above questions, please explain
your answer here:
Parent signature: ________________________________ Date:__________
If you answered “yes” to any of the above questions, your child’s primary
care provider should check his heart, and sign this document.
I, the primary care provider have performed a cardiovascular exam and risk
factor assessment on this patient:
Physician’s Signature: ____________________________
Date: _______

BELMONT HILL SCHOOL
PHYSICIAN'S REPORT
This form is to be filled out by your son's physician and returned to the School.
The Health Clinic will be available to all students for all health matters while
school is in session.
STUDENT'S NAME:
AGE____ FORM _____
DATE OF EXAMINATION: (__________________)
Height: _____________ Ears: ____________ Heart: ______________
Weight: ______________ Eyes: ____________ Lungs: _____________
Blood Pressure: ________ contacts: ________ Neurological: ________
Pulse Rate: ____________ glasses: _________ Teeth: ______________
POSTURAL SCREENING:
Diagnosis: Normal Therapy:
Observation:
Scoliosis:
Bracing:
Lordosis:
Other:
Kyphosis:
LABORATORY FINDINGS: (optional)
Hemaglobin: _______ Urinalysis: ____________
Hematocrit: ________ Cholesterol: ___________
Recent immunizations (include most recent tetanus booster or Td): _________
(Meningococcal Vaccine is strongly recommended)
Note: Belmont Hill School is an international compository, with students and
faculty traveling all over the world, sometimes to areas endemic of TB; every year
we pick up new cases of exposure.
Recent TB mantoux test: _______/_________ (required for all new students, as
Date Result well as those with an elevated risk
of exposure. Check w/physician)
I have examined this student and find him to be free of any communicable disease.
There are no apparent contraindications to his participating in routine and
competitive school sports and activities except as noted below:
Date: ________Signed:_______________________________________________
Physician's Name: ___________________________________________________

Medical Information Summary
(Please attach a copy of the student’s most recent physical exam)

MEDICAL INFORMATION SUMMARY
(to be completed by parent )
STUDENT’S NAME
Form
The following information will help us in providing the best possible care for your son. Please
consider each question – and answer to the best of your knowledge.
HEALTH HISTORY:
YES NO
Allergy
Asthma
Fainting/Convulsions
Heart Murmur / Problems
Rheumatic Fever
Kidney Disease
Chronic Sprains, strains, dislocations
Fractures
Surgery
Loss of a paired organ
Concussion
Mononucleosis
Diabetes
If “YES” to any of the above, please explain and give dates:
Please list regular and/or periodic medications and reason for taking them: (for example:
Accutane, insulin, Ritalin, Prozac)
There are occasions when a school’s ability to respond optimally to students is affected by
knowledge of their mental health problems and therapy.
Are there any identifiable mental health concerns in your son or in your family
Yes________ No________
Does your son see a mental health counselor If so, please give name:
Failure to disclose to the School pertinent information regarding your son’s medical history,
including medications, may jeopardize your son’s care and treatment. Discretion will be used in
sharing this information. If you feel strongly about not sharing something in particular, please
note on this sheet, or call Donna David (nurse) 617-993-5335.
Date:
Signature of Parent