The University of Massachusetts Amherst Juniper Institute ... · The University of Massachusetts Amherst Juniper Institute for Young Writers July 21-28, 2019 Health Forms Packet M

The University of Massachusetts Amherst Juniper Institute for Young Writers July 21-28, 2019

Health Forms Packet

Massachusetts law requires the consent of a parent/guardian for medical care of persons under18 years of age. If your dependent is a student at the University of Massachusetts Amherst, or attending a program at the University of Massachusetts Amherst, the Medical and Immunization History Forms (p1-3) must be completed along with Consent to Treat (p4) before treatment can be provided. If your dependent takes prescription medications, please complete Authorization to Administer (p 5-8) and/or Approval for Self-Administered Medication (p 8) as appropriate. Return all forms by 5/1/19. Mailing address and checklist provided on p9.

FORM I: MEDICAL AND IMMUNIZATION HISTORY

SECTION 1 (To be completed by parent or guardian.)

Participant Last Name, First Name, MI (print): ___________________________________________ Gender Pronouns: ___________________ Gender (optional):____________________ Birth date (Month/Day/Year): ___________________

Address: __________________________________________________ City/State/Zip: __________________________________________________ Parent/Guardian name: ______________________________ Gender Pronouns: ______________ Phone (day): ___________________ Phone (evening): ____________________

❏ check here if above is legal guardian ❏ check here if above is emergency contact

Parent/Guardian name: ______________________________ Gender Pronouns: ______________ Phone (day): ___________________ Phone (evening): ____________________

❏ check here if above is legal guardian ❏ check here if above is emergency contact

Family physician name: _____________________________________

Address: _____________________________________

Phone: ______________________________________ Family dentist name: _____________________________________

Address: _____________________________________

Phone: _____________________________________ Medical insurance company: ______________________________________________

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Policy number:______________________________________

SECTION 2: PHYSICAL EXAMINATION: must have been done by a medical provider within the preceding 12 months. This section may be replaced by health records provided by physician’s office. Please initial here ______ if attaching physician’s office records in lieu of filling out Section 2.

Participant Last Name, First Name, MI (print):_________________________________________ Date of birth: _________________________________________ MEDICAL HISTORY (please note significant disorders): Allergies: _________________________ Heart: ____________________________ Tuberculosis: _______________________Kidney: ___________________________ Whooping Cough: __________________ Diabetes: __________________________ Lung:_____________________________ Varicella: __________________________ Neurological:______________________ Disabilities:_________________________ Other:_______________________________________________________________ Pertinent medical history:

___________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Summary of significant treatment program, including names and doses of medications to be used while at program (medications MUST be in a container with the original label): ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

SECTION 3: REQUIRED IMMUNIZATIONS This section may also be replaced by health records provided by physician’s office. Please initial here ______ if attaching physician’s office records in lieu of filling out Section 3

MEASLES, MUMPS AND RUBELLA (MMR) VACCINE First dose must be after age 12 months; 2 doses required. MMR #1 ____/____/____ MMR #2 ____/____/____ POLIO VACCINE A minimum of three doses of either inactivated polio vaccine (IPV) or oral polio vaccine (OPV) are required. If a mix of (IVP/OPV) was used, four doses are required. Completed primary series of polio immunizations? YES NO Dates:

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____/____/____ ____/____/____ ____/____/____ ____/____/____ DIPHTHERIA AND TETANUS TOXOIDS AND PERTUSSIS VACCINE Minimum of four doses of DTaP/DTP/DT or at least three doses of Td is required. A booster dose of Td is required for all campers and staff who will be entering grades seven through 10. For campers and staff who will be entering grades 11 and 12, a booster of Td is required if it has been more than 10 years since the last dose of DTaP/DTP/DT/Td. (Tdap is also acceptable.) Completed primary series of DTaP/DTP/DT? YES NO Dates: ____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____ Date last Td HEPATITIS B Three doses of Hepatitis B vaccine are required if born on or after Jan. 1, 1992. Dose # 1 ____/____/____ Dose #2 ____/____/____ Dose #3____/____/____ EXCEPTIONS •RELIGIOUS OBJECTION: The individual must submit a written statement, signed by a parent/guardian if a minor, to the effect that the individual is in good health and stating the reason for such objections. •MEDICAL: The individual must submit certification by a physician stating that the physical condition of the individual is such that his or her health would be endangered by such immunization. Health care provider signature and/or stamp: ___________________________________________________________________________ Printed name: _______________________________________________________ Address: _______________________________________________________ City/State/Zip: _______________________________________________________ Phone: _______________________________________________________ Date: _______________________________________________________

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FORM II: CONSENT TO TREAT MINOR PATIENTS FORM

If you are under 18 years of age, your parent or legal guardian must complete this form. I, _______________________________________________ (print name) am the parent/guardian of ______________________________________________ (print name), date of birth __________, who is currently a minor. By printing and signing my name, I attest that I am the parent and/or legal guardian of the participant, that I am authorized to act on behalf of and legally bind the participant and that the signature or agreement of another parent/guardian is not required. I authorize University Health Services, University of Massachusetts Amherst, to provide medical and/or mental health care to my dependent, including but not limited to, diagnostic examinations, medical treatment, and mental health counseling. I understand that if an injury/illness is determined to be life-threatening, that an ambulance will be called to take my dependent to a hospital and that the provider will make every effort to contact me. I further understand that once my dependent reaches the age of maturity, my consent for treatment is no longer required. By my signature, I acknowledge that I have read and understand this consent, and that any questions I have prior to signing this can be answered by calling University Health Services, (413) 577-5000. ______________________________________________ Parent/Guardian – Full Name (print) ______________________________________________ Parent/Guardian Signature ______________________________________________ Date

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FORM III: AUTHORIZATION TO ADMINISTER MEDICATION TO A MINOR PARTICIPANT To be completed by parent/guardian: Participant Last Name, First Name, MI (print): ___________________________________________ Gender Pronouns: ___________________ Birth date (Month/Day/Year): ___________________

Food/Drug Allergies: ____________________________________________________________

1.

Name of Medication: _______________________________ Dose : ___________

Diagnosis: (at parents’ discretion):_______________________________________

Name of Licensed Prescriber: __________________________________________

Prescriber Telephone: _____________________

Route of administration:_________________ Frequency: ____________________

Special Directions (e.g. on empty stomach/with water):

_______________________________________________________________

Date Ordered: __________ Duration of Order: _________ Quantity Received:______

Expiration date of Medication Received: ______________________

Special Storage Requirements:

_________________________________________________________

Specific Precautions:

___________________________________________________________

Possible Side Effects/ Adverse Reactions:

_______________________________________________________________

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2.







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3.






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Other medications self-administered at parents’ discretion (must also complete Form IV below):

_____________________________________________________________________

_____________________________________________________________________

I hereby authorize THE JUNIPER INSTITUTE FOR YOUNG WRITERS to administer to my child, ___________________________________________ (NAME OF CHILD) the medication(s) listed above, in accordance with 105 CMR 430.160. 105 CMR 430.160(A)

Medication prescribed for participants shall be kept in original containers bearing the pharmacy label, which shows the date of filing, the pharmacy name and address, the filling pharmacist’s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statement, if any, contained in such a prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for participants shall be kept in the original containers containing the original label, which shall include the directions for use. 105 CMR 430.160 (C)

Medication shall only be administered by a health supervisor* or by a licensed healthcare professional authorized to administer prescription medications. The healthcare consultants shall acknowledge in writing

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the list of medications administered at the program. If the health supervisor is not a licensed healthcare professional authorized to administer prescription medications, the administration of medication shall be under the professional oversight of the healthcare consultant. Medication prescribed for participants brought from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian. 105 CMR 430.160(D)

When no longer needed, medication shall be returned to a parent or guardian wherever possible. If the medication cannot be returned, it shall be destroyed. *Health Supervisor: A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross first aid (or its equivalent) and CPR, trained in the administration of medications, and under the professional oversight of a licensed healthcare professional authorized to administer prescription medications.

Parent or Guardian Signature Date FORM IV: PARENT/GUARDIAN APPROVAL FOR SELF-ADMINISTERED MEDICATION

As the parent or guardian of _______________________________(Participant Full Name) I give permission for the above listed participant to have readily available (carry or possess outside of the regular supervision of Juniper’s health staff) and self-administer as medically necessary, the following specific medications and devices: (Check all that apply)

❏ Asthma Inhaler

❏ Epinephrine Pen

❏ Fingerstick glucose monitoring equipment

❏ Insulin and injection syringes

❏ Insulin pump

❏ Birth Control Pills

I confirm that the participant has the knowledge and the skills to have readily available and to safely self-administer the above medication/devices at Juniper, and will be bringing all necessary medications and supplies with them to Juniper.

Parent or Guardian Signature Date

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FOR HAYDEN SCHOLARS ONLY: PARENT/GUARDIAN APPROVAL FOR DROP-OFF: Please indicate below if you will meet your child/ward at their drop-off location (their school or Yankee Stadium), or if we have your permission to drop them off without a parent/guardian present. As the parent or guardian of _______________________________ (Participant Full Name) I give permission to drop them off only with a parent/guardian present. As the parent or guardian of _______________________________ (Participant Full Name) I give permission to drop them off without a parent/guardian present. Notes: ________________________________________________________________ ________________________________________________________________ Parent or Guardian Signature Date

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Please sign and mail all forms to this address by May 1, 2019: Juniper Institute for Young Writers c/o University Conference Services 810 Campus Center, 1 Campus Center Way University of Massachusetts Amherst, MA 01003

For questions about on-campus treatment, call University Health Services, (413) 577-5000

For questions about medications, health needs, or routine medical treatment that will be needed while at Juniper, call Rebeccah Johnson, Conference Registrar, (413) 577-8102

Checklist for completing forms:

Required from every participant (regardless of age): ❏ FORM I: MEDICAL AND IMMUNIZATION HISTORY

❏ Section 1 (completed by parent/guardian) ❏ Physical Exam & Immunization history:

❏ Section 2 & 3 (completed by physician) OR…

❏ Physical and Immunization records from your pediatrician’s office Required from participants under age of 18:

❏ FORM II: CONSENT TO TREAT MINOR PATIENTS FORM Required from any participant under age of 18 bringing medication to Juniper:

❏ FORM III: AUTHORIZATION TO ADMINISTER MEDICATION TO A MINOR or/and…

❏ FORM IV: PARENT/GUARDIAN APPROVAL FOR SELF-ADMINISTERED MEDICATION

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Documents

The University of Massachusetts Amherst Juniper Institute ... · The University of Massachusetts Amherst Juniper Institute for Young Writers July 21-28, 2019 Health Forms Packet M