Brewster Academy Summer Session

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

Dear Parents,

Being able to contact you is crucial to us. In the past, there have been

difficulties reading handwriting on student forms, especially contact

information and email addresses.

Please send an email to

[email protected]

with the

following information as soon as possible:

• Name of Parent(s)/Guardian(s)

• Name of student

• Mailing address

• Home, work, fax and cell phone numbers

• Email address

In addition, should you be away during the time your child is enrolled in

summer session, please provide us with dates, and an alternative phone

number where you can be reached.

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Brewster Academy Summer Session

8

0 Academy Drive, Wolfeboro, NH

03894

TRAVEL INFORMATION

Arrivals:

International Students

:

Orientation begins on Thursday, June 21, 2012. For students who will be traveling with parents/

guardians, there will be an information session beginning at 3 PM. For students flying alone, we will

make arrangements to greet your child whenever his/her flight arrives.

US Students:

Registration is on Saturday, June 23, 2012 from 11 AM – 2:30 PM. There will be an orientation/

information session beginning at 3 PM for all students and parents. For students flying alone, it is best

to schedule a flight that arrives mid-morning, so that he/she will be able to participate in the orientation.

*Note: there is no public transportation to Wolfeboro, New Hampshire.

Airport Information:

Flights should be scheduled to arrive at either Manchester-Boston Airport (MHT) in Manchester, New

Hampshire, or Logan International Airport (BOS) in Boston, Massachusetts. For domestic flights,

Manchester would be the preferred choice, as it is a smaller airport and much closer to campus. Summer

Session personnel will meet your child for his/her flight at baggage claim. The Brewster representative

will carry a sign that states “Brewster Academy”, as well as your child’s name. If your child is being

chaperoned by airline personnel using the unaccompanied minor service, our designated Brewster

representative will meet your child and his/her chaperone at the gate.

There is an additional cost for airport transportation. For Manchester-Boston Airport (MHT), the cost is

$80 one way, and for Logan International Airport (BOS), the cost is $120 one way.

Please return your travel form as soon as possible, as well as a copy of the flight itinerary that includes

any connecting flights. Please also indicate if your child will be traveling using the unaccompanied

minor service (for both arriving and departing flights).

Departures:

Brewster Academy Summer Session concludes at noon on Thursday, August 2, 2012 for all students.

Parents/Guardians who plan to pick up their child are invited to attend our “graduation” mid-morning

that day and join us for lunch. For students who will be flying, please make arrangements for a flight

departing after 4:30 PM on Thursday, August 2, 2012, or for the morning of Friday, August 3, 2012.

Students departing the morning of Friday, August 3, 2012 will remain on campus with Summer Session

personnel. A Brewster Academy representative will escort each student to the security checkpoint for

his/her outgoing flight.

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Brewster Academy Summer Session

8

0 Academy Drive, Wolfeboro, NH

03894

DRIVING DIRECTIONS TO BREWSTER ACADEMY

From Boston, Massachusetts (Wolfeboro is about a two-hour drive north of Boston.)

(A)

Take Interstate 93 north to Concord, NH. Go east on Interstate 393, which becomes NH

Route 4 after a few miles. Take this to the Epsom Circle where you will intercept Route 28. Go

north on Route 28 about 18 miles to Alton Circle. From there, continue on Route 28 about 12

miles to Wolfeboro and Brewster.

OR

(B)

Take Route 1 north to Interstate 95. Follow Interstate 95 (pass through a tollbooth) to New

Hampshire. At Portsmouth, look for the New Hampshire Lakes and Mountains sign and go

north on the Spaulding Turnpike (pass through two more tollbooths) to Rochester. At exit 15

go west on Route 11 and continue about 14 miles to the Alton Circle. From there, go north on

Route 28 about 12 miles to Wolfeboro and Brewster Academy.

Route 28 goes through Wolfeboro. Brewster Academy is on the left. Look for us after you

pass Huggins Hospital on your right. Use the “Student Parking and Deliveries” entrance.

Registration will be held at the Spaulding/ Emerson Student Center.

Driving from West of Boston, Massachusetts

Take the Massachusetts Turnpike east to Interstate 495. Go north to Interstate 93 and follow

directions found in (A), above.

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Brewster Academy Summer Session

8

0 Academy Drive, Wolfeboro, NH

03894

TRAVEL FORM

Note: Manchester-Boston Airport (MHT) is the preferred option for Summer Session students. It is a small international airport that services several airlines. Manchester Airport in Manchester, NH is only one hour and fifteen minutes from campus. The other alternative is Logan Airport (BOS) in Boston, MA, which has five terminals, and is over two hours from Brewster.

____________________________________________________________________________________________________

Student Name Parent/Guardian Name

____________________________________________________________________________________________________

Phone Number (home/work) FAX Number Email Address

Arrival

Parent/Guardian will be driving student to Brewster Academy on ________________________

(Date) 

Student will need to be picked up at

Manchester-Boston Airport (MHT), Manchester, NH. The cost

for airport transport is $80 one way.

___________________________________________

(Date) (Time)

PLEASE ATTACH FLIGHT ITINERARY

Is your child traveling with an airline chaperone using the unaccompanied minor service?

YES NO 

Student will need to be picked up at Logan

Airport (BOS), Boston, MA. The cost for airport

transport is $120 one way.

___________________________________________

(Date) (Time)

YES NO

Departure

Parent/Guardian will be picking up student Brewster Academy on ________________________

(Date) 

Student will need a ride to Manchester-Boston

Airport (MHT), Manchester, NH. The cost for airport

transport is $80 one way.

___________________________________________

(Date) (Time)

YES NO 

Student will need a ride to Logan Airport (BOS), Boston, MA. The cost for airport transport is $120 one way.

___________________________________________

(Date) (Time)

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

Student Name: _____________________________________________________________________

Parent/Guardian Name:_______________________________________________________________

Student Drawing Account

Boarding students are required to either have a student drawing account OR their own debit/credit card for personal expenses. Students are not to keep large sums of cash in their room. The Brewster Academy

Business Office provides an allowance service, distributing funds each Thursday at a designated time.

Allowance is typically used for purchasing snacks, ice cream downtown, or for doing laundry. Recommended weekly allowance typically falls between $25-$50 depending on the needs of the student. There will be potential movie/mall trips most weekends. For Sunday trips, admission costs/tickets and meals are provided, however, if the student wishes to buy souvenirs or snacks, they must use their own money. For the final weekend, BASS students will have a trip to Boston, MA, where they will most likely desire additional money.

Please note- the first allowance is not distributed immediately. Be sure to provide your child with a modest amount of spending money for his/her first week at BASS!

Allowance Distribution Dates: Amount to be given: 1) Thursday, June 28, 2012 $__________ 2) Thursday, July 5, 2012 $__________ 3) Thursday, July 12, 2012 $__________ 4) Thursday, July 19, 2012 $__________ 5) Thursday, July 26, 2012 (Boston trip weekend!) $__________ Travel money/allowance to be distributed on Wednesday, August 1, 2012 $__________

Mandatory room key deposit*

$ 25.

TOTAL PAYMENT $__________

Method of Payment:

[ ] Credit Card (circle one): MasterCard Visa American Express

Name as is appears on card:____________________________________________________________________________ Card Number:_______________________________________________________ Expiration Date:_____________ Billing Address: _____________________________________________________________________________________ Home Phone Number:________________________________________________ Email:_____________________ Parent/Guardian Signature:_____________________________________________________________________________ [ ] I have enclosed a check, payable to Brewster Academy.

[ ] Student has his/her own debit/credit card to be used for personal expenses.

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

Student Name: _____________________________________________________________________

Parent/Guardian Name:_______________________________________________________________

Media Release

Periodically, we use student photographs, video footage and names for news releases, school

publications, and the Summer Session video. We need your permission to use your child’s name,

photograph and/or video footage.

[ ] Yes

[ ] No

Brewster Academy may use my son/daughter’s name for news releases

and school publications (Newsletter, Catalog, Brewster Review, website)

[ ] Yes

[ ] No

Brewster Academy may use my son/daughter’s photo for news releases

and school publications (Newsletter, Catalog, Brewster Review, website)

[ ] Yes

[ ] No

Brewster Academy may film my son/daughter for the BASS video.

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Student Name: ____________________________________________________________________

Parent/Guardian Name:_____________________________________________________________

ABOUT YOUR MACINTOSH LAPTOP

Brewster Academy will provide your child with a Macintosh laptop computer for his/her use during

the program at no additional cost above the tuition fee. As the laptop is the property of Brewster

Academy, it is expected that all students will return the computer at the conclusion of Summer

Session in the same condition in which it was received, with the understanding that all machines will

undergo normal wear and tear. Students are discouraged from decorating their laptop with stickers,

and required to carry it in the computer bag provided at all times when in transit between classes and

their dormitories. Should the student experience complications with the laptop (examples: error

messages when trying to run a program, the computer not starting) he/she should immediately bring it

to the technology office for assessment or repairs, as the use of a proper functioning computer is

essential. Often a solution is as simple as reinstalling software.

All laptops have a warranty from Apple Computer against mechanical defects under normal use. In

addition, Brewster Academy has a Laptop Computer Insurance Policy with a deductible of $250 in

cases of accidental damage, loss or theft. In some rare cases, the insurance company may refuse to

pay if it can be shown that the damage was due to abuse (for example, damage resulting from a

computer tumble down the stairs) or neglect (for example, the computer being left out in the rain).

I have read the above laptop information and understand that I will be held financially responsible for

the $250 deductible in cases of insurance claims. I further understand that if the insurance company

determines there is damage to abuse I will be responsible for the entire repair costs.

Parent Signature_________________________________________________________ Date___________ Billing Address __________________________________________________________________________ _______________________________________________________________________________________

Brewster Academy Summer Session

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

FAX: (603) 569-7050

IMPORTANT INFORMATION CONCERNING MEDICAL FORMS

1. All health forms for Brewster Academy Summer Session must be completed and returned to the Summer Programs office no later than June 1, 2012. The completed health forms should be returned to the address above.

Students will not be allowed to participate in Brewster Academy Summer Session or stay on campus until these forms have been received.

2. All students must have had a physical exam within one year of arrival at summer session. If your child will not have had a physical within this time frame, please schedule one prior to the June 1st deadline for returning the health form. Please inform us of the physical exam date, should it interfere with the paperwork arriving on time.

3. The physical exam and immunization form must be completed by a physician, physician’s assistant or nurse practitioner. If your child takes prescription medication, the medication information page must also be completed by their health care provider. All vaccinations including tetanus must be up to date. Please review your child’s health and vaccination record with the physician to make sure that your child’s immunizations are in compliance with New Hampshire law.

4.

For US students: Please attach a photocopy of both sides of the health insurance card that covers your child’s medical expenses. For international students, we will obtain health and

accident insurance coverage through Ace Insurance Company for your child for the period of time he/she is enrolled in Brewster Academy Summer Session. The reason we arrange for this insurance

is that local physicians will not accept medical insurance from outside of the United States.

Students must have health insurance that will cover emergency medical services by a local provider. All medical expenses are the responsibility of the student’s parent or guardian.

Medical Paperwork Checklist:

Medical Authorization Form

Physical Exam (completed by a physician)

Medical History

Immunization Record

Medication Information Form (completed by a physician)

Prescription Form

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

Medical Authorization

This form constitutes a permission statement that must be completed and signed by a parent or guardian and student. Student’s name ________________________________________________________Birth date_____________ Grade__________ Home address________________________________________________________________________________________________ Number and street City State Country Zip Code

____Male ____Female ____Day ____Boarding Student cell phone ___________________________________

Student resides with: Both Parents______ Father ______ Mother ______ Other (specify)_________________

Father/Guardian full name: Res. phone

Address: Bus. phone

Cell phone

Email Address: Fax phone

Mother/Guardian full name: Res. phone

Address: Bus. phone

Cell phone

Email Address: Fax phone

For International students, emergency name and contact number of guardian, relative, friend or consultant in the United States, if available:__________________________________________________________________________

Health insurance is mandatory for all students. International students will be enrolled in ISM/ACE insurance. U.S Students please attach a copy of front & back of health insurance card and prescription card.

Policy Holder Name (required)____________________________ Policy Holder DOB (required)__________________ Confidentiality

We respect the privacy of our students’ medical care, yet we urge students to communicate with their parents about any medical issues. Parents and students agree, as a condition of enrollment, to consent to the release of any medical records, including information relating to drug or alcohol treatment and testing and mental health records. Such records will be released to faculty and administrators at Brewster Academy, and their agents, on a need to know basis when a health care professional at Brewster Academy has determined such release is in the best interest of the student and/or the community.

Medical Authorization

I hereby consent for the Director of Health Services at Brewster Academy to direct health care providers to carry out accepted procedures for diagnosis, immunization, medical and minor surgical treatment or counseling for my child while attending school. I authorize the Health Center to share necessary and appropriate medical information with the treating physician and to release information necessary to process insurance claims. I authorize the nursing staff to administer OTC (over the counter) and prescription medication as directed and to provide medication to my child for self-administration if needed. I also give permission for my child’s immunizations to be completed in accordance with all applicable laws with the cost to be billed to me.

Emergency Medical Authorization

In rare instances when any emergency arises and where delay might jeopardize the recovery of my child, I hereby authorize the appropriate physicians or surgeons to give necessary anesthesia and perform emergency surgery on my child. I understand that in the event of an emergency, the School will use all reasonable efforts to contact me as soon as possible.

Persons treating my child should be aware of the following Allergies or Medical Conditions:

_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________ Signature of parent/guardian Date Student signature Date

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

Physical Exam

To be completed by a M.D., D.O., A.R.N.P., or P.A.

________________________________________________________________________________________________

Name of Student Date of Birth Age Allergies

________________________________________________________________________________________________ Routine or P.R.N. medications (if yes, prescribing MD please complete Medication information form)

Are all NH required immunizations up to date? (See immunization form) ______________________ Please list boosters given at this visit ___________________________________________________

Blood Pressure: ________/________ Heart rate: ________Height _________ Weight______ International Students: TB: (Mantoux test REQUIRED within 6 months of arrival on campus)

Date: _______/_______/_______ mm induration: _________________

If greater than 10mm, CXR required. CXR results: _________________Include copy of report. Was INH therapy started? If so, please provide details.

Are there abnormalities in any of the following systems? (please explain)

Head, ears, nose, throat ______________________________________________________________________ Hearing __________________________________________________________________________________ Eyes _____________________________________________________________________________________ Respiratory _______________________________________________________________________________ Cardiovascular ____________________________________________________________________________ Gastrointestinal ____________________________________________________________________________ Musculoskeletal ___________________________________________________________________________ Metabolic/Endocrine ________________________________________________________________________ Neuropsychiatric ___________________________________________________________________________ Skin _____________________________________________________________________________________ Is there any reason that this person should not participate in a mandatory, adventure recreation program? If yes, please explain. _________________________________________________________________________________________ ________________________________________________________________________________________________

________________________________________________________________________________________________

Signature of M.D., D.O., A.R.N.P., or P.A. Date

Printed Name of Physician:______________________________________________ Address: ____________________________________________________________ Phone: ___________________________________FAX:_______________________ Please attach your business card.

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

Medical History

To be completed by parent and student

Student_______________________________________ Date of Birth_

Family History: Specify relationship to student (parents, grandparents, siblings only)

_______ Depression _______ Cancer _______ Diabetes _______ Asthma, allergies

Personal History: check all that the student has had:

_______ ADHD _______ High blood pressure _______ Surgery

_______ Anemia _______ Low blood pressure _____ Appendectomy

_______ Asthma (see below) _______ Insomnia _____ Tonsillectomy

_______ Anxiety _______ Kidney problems _____ Hernia repair

_______ Back problems _______ Malaria _____ Other

_______ Cancer _______ Pneumonia _______ Ulcer

_______ Chicken pox(date or age) _______ Hepatitis _______ Tuberculosis _______ Chronic sinusitis _______ Lyme disease _______ Weight gain or loss

_______ Colitis _______ Measles _______ Whooping cough

_______ Concussion _______ Migraines

_______ Depression _______ Mononucleosis Women Only:

_______ Diabetes _______ Mumps _____ Irregular periods

_______ Eating disorder _______ Seizure Disorder _____ Severe cramps _______ Fainting or dizziness _______ Thyroid disorder _____ Oral contraceptive _______ Heart murmur _______ Urinary tract infection

Allergies: ______________________________ Typical response: _______________________________________

Treatment: _____________________________ Does your child carry an Epi-pen? _________________________

Asthma: Inhaler or treatment type: _______________________________________________________________

How often is inhaler used? ___________________ What triggers asthma attacks?__________________

Please send a spare inhaler to be kept in the Health Center.

Please document any muscle, bone or joint injuries. _________________________________________________________ Please explain any need for counseling or treatment for depression, eating disorder, attempted suicide or other emotional problems? (Use separate paper if needed) _________________________________________________________________ Please explain any hospitalization or ongoing treatment by physicians or other practitioners in the past 5 years?

___________________________________________________________________________________________________ Have there been any important changes in your child’s life recently? (e.g. divorce, separation, illness or family death) ___________________________________________________________________________________________________ Please use additional paper if needed or call the Health Center (603-569-7121) with your concerns or questions. If your child has any condition (e.g. diabetes, depression, thyroid disorder, epilepsy, etc.) that requires special monitoring or medication, please call the Health Center and speak with one of the nurses. Honest disclosure of medical history is necessary to provide appropriate care to your child.

___________________________________________________________________________________________________

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

Immunization Record -

to be completed by medical provider

The State of New Hampshire and Brewster Academy have the following immunization requirements. All immunizations must be completed PRIOR to student’s arrival on campus.

Name of student: _________________________________ Birth date:

REQUIREMENTS:

Diphtheria, Tetanus, Pertussis (DTP): 4 or more doses; 1 dose must be after the child’s fourth birthday.

Tetanus, Diphtheria, Acellular Pertussis (Tdap): One-time dose of Tdap after 11 years of age and 5 years since last

tetanus-toxoid containing vaccine.

Polio (OPV/IPV): 3 doses of OPV/IPV with the last dose after the child’s fourth birthday or 4 doses regardless of age at

administration.

Measles, Mumps, Rubella (MMR): first dose on or after 1 year of age, second dose at least 30 days after first.

Varicella (chicken pox vaccine): One dose unless first dose administered after 13 years of age, then two doses required; Or,

documented history of disease.

Hepatitis B Vaccine: Three doses required.

Meningococcal Vaccine: One dose required after 11 years of age.

*International Students: TB (Mantoux test REQUIRED within 6 months of arrival on campus) If induration is greater

than 10mm, CXR (chest x-ray) required.

VACCINE

DATE EACH DOSE IS GIVEN (month/day/year)

VACCINE

1

ST

₂

ND

₃

RDRD

₄

TH

₅

TH

Polio

DPT

Td Booster

Tdap Booster

Hepatitis B

Varicella

OR Date of disease:

MMR

Meningococcal

TB - Mantoux

(International

Students only)

Date:

mm induration:

>10mm, CXR:

_________

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

Medication Information

To be completed by M.D., D.O., A.R.N.P., or P.A. if student is on any medication.

Student Name: ___________________________________________________ DOB: ________________

Medication Allergies:____________________________________________________________________ [ ] Student is not taking any prescription medication

[ ] Student medication information is indicated below.

Doctor, please be aware that a student is required to take his medication as ordered. Please discuss with student and parents if medication is required on non-class days to avoid confusion and insure compliance.

Medication: ____________________ dose: _____________________ frequency:___________ route:_________ Reason for medication:________________________________________________________________________

How long has the student been on this med? ________________________________________________________ Please check one: _____ Med should be taken at scheduled frequency only for class and study time.

_____ Med should be taken at scheduled frequency every day including non-class days.

Physician’s Name Printed:_______________________________________________________________________ Phone: __________________________________________ Fax:_______________________________________ Address: ____________________________________________________________________________________ Physician’s Signature:_____________________________________________________________ Date:________

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Brewster Academy Summer Session

80 Academy Drive, Wolfeboro, NH 03894

PRESCRIPTION FORM

In case of an emergency or unexpected illness that requires my son/daughter to have a prescription filled, or in the event of other charges that medical insurance refuses; please use the following information to charge my credit card:

Student Name: ________________________________________________________________________ Parent/Guardian Name:_________________________________________________________________ Credit Card (circle one): MasterCard Visa American Express

Last 3 digits of security code on back of card: ____________________________

Name as it appears on card:______________________________________________________________ Card Number:______________________________________________ Expiration Date:____________ Billing Address: ______________________________________________________________________ ____________________________________________________________________________________ Home Phone Number:________________________________ Email:__________________________ Parent/Guardian Signature:______________________________________________________________