Order now and save! $920 after 8/15/12 - Suffield Academy
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<strong>Suffield</strong> <strong>Academy</strong><br />
Registration Packet Return Checklist for NEW DAY STUDENTS<br />
Forms required for students due by July <strong>15</strong>, 20<strong>12</strong><br />
Database Verification Sheet<br />
Ack<strong>now</strong>ledgement of <strong>Suffield</strong> <strong>Academy</strong><br />
Medical Philosophy<br />
Physical Examination Record for New<br />
Students<br />
Immunization History for New Students<br />
Permission for Medical or Surgical<br />
Treatment for All Students<br />
Permission to Administer Influenza<br />
Vaccine<br />
<strong>Suffield</strong> <strong>Academy</strong> Concussion<br />
Testing<br />
Student Health Insurance<br />
Waiver/Enrollment<br />
Copy of Health Insurance Card<br />
(front <strong>and</strong> back)<br />
Student Debit Card Form<br />
Photo Permissions & Press<br />
Release Form<br />
Additional forms, if applicable.<br />
Administration of Prescription Medicine<br />
by School Personnel Authorization.<br />
Music Lesson Registration<br />
Laundry/Dry Cleaning Service
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suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
CONSENT TO USE OF ELECTRONIC SIGNATURES PROGRAM<br />
To the Parent(s) or Legal Guardians of Students at <strong>Suffield</strong> <strong>Academy</strong>, classes of 2013, 2014, 20<strong>15</strong> <strong>and</strong> 2016:<br />
As of June 1, 20<strong>12</strong>, <strong>Suffield</strong> <strong>Academy</strong> (“<strong>Suffield</strong>”) will begin implementing an Electronic Signature Program for the 20<strong>12</strong>-2013 academic year <strong>and</strong> beyond.<br />
Under this system, parents <strong>and</strong> legal guardians of <strong>Suffield</strong> students sign certain forms by completeing them electronically during the course of their child’s time<br />
at <strong>Suffield</strong> <strong>Academy</strong>. These forms will be electronically retained by <strong>Suffield</strong>.<br />
Participation in the Electronic Signature Program is optional.<br />
To participate in the Electronic Signature Program, please read the following information carefully. If you have any questions regarding<br />
the Electronic Signature Program, please contact Patrick Booth, Chief Financial Officer at pbooth@suffieldacademy.org.<br />
Electronic Signature Program: Parent Information<br />
Participation is optional. <strong>Suffield</strong>’s Electronic Signature Program is designed to be an optional convenience for parents. You are not required to participate.<br />
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<br />
attached forms <strong>and</strong> send them back to <strong>Suffield</strong> <strong>Academy</strong>, 185 North Main Street, <strong>Suffield</strong>, Connecticut 06078. However, we strongly urge you to consider the<br />
benefits of an electronic signature, including better data accuracy, <strong>and</strong> a more green approach to paper management.<br />
You may withdraw your consent at any time. If you choose to participate in the Electronic Signature Program <strong>now</strong>, but change your mind later, you<br />
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<br />
documents you have previously signed electronically.<br />
To withdraw your consent, you may print out <strong>and</strong> sign a “Withdrawal of Consent to Use of Electronic Signature” form, which is located in the Parent Portal of<br />
the <strong>Suffield</strong> <strong>Academy</strong> website on the Forms & Documents page (login required). Return the form to the <strong>Suffield</strong> <strong>Academy</strong> Business Office via mail or fax.<br />
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<br />
have signed electronically, please call or email Kim Goodwin 860-386-4400 or kgoodwin@suffieldacademy.org with your request.<br />
Your consent applies only to certain documents. Your consent to participate in the Electronic Signature Program applies only to online forms<br />
(e.g. emergency medical treatment, field trip approval, re-enrollment contracts, plus others as they become necessary.)<br />
You must inform <strong>Suffield</strong> <strong>Academy</strong> of any changes in your email address. To effectively participate in the Electronic Signature Program, you<br />
must agree to inform <strong>Suffield</strong> <strong>Academy</strong> promptly of any changes in your email address.<br />
Consent to Electronic Signatures <strong>and</strong> Documents: By completing <strong>and</strong> emailing this consent form to Kim Goodwin, kgoodwin@suffieldacademy.org<br />
you are providing electronic consent to the use of electronic documents <strong>and</strong> signatures during your child’s <strong>Suffield</strong> <strong>Academy</strong> enrollment.<br />
Specifically, you are ack<strong>now</strong>ledging receipt of this form <strong>and</strong> consenting to the use of electronic documents, email delivery of documents, <strong>and</strong> electronic<br />
signatures in any transactions involving you, your child, <strong>and</strong> their academic experience at <strong>Suffield</strong> <strong>Academy</strong>, including boarding <strong>and</strong> all extracurricular activities.<br />
By checking this box you agree that the addition of your child’s student ID in the top right<br />
h<strong>and</strong> corner of all forms acts as an electronic signature on all <strong>Suffield</strong> <strong>Academy</strong> forms.<br />
Parent or Guardian Name (please print <strong>and</strong> sign here if you intend to use a printed copy of this form)<br />
date<br />
[<br />
FORM: SIGNATURE / DUE: 07.<strong>15</strong>.<strong>12</strong>
suffield academy<br />
<strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>-2013 ACADEMIC CALENDAR<br />
September<br />
Tuesday 4 Varsity C<strong>and</strong>idates Registration (by invitation) – 10:00 A.M.-<strong>12</strong>:00<br />
Thursday 6 New International Students Registration – 9:30-11:00 A.M.<br />
Thursday 6 Remaining Seniors Registration – 9:30-11:00 A.M.<br />
Friday 7 Remaining Grades 9, 10, 11 Students Registration – 1:00-3:30 P.M.<br />
Monday 10 Convocation; classes begin<br />
October<br />
Friday-Saturday <strong>12</strong>-13 Fall Parents’ Weekend<br />
Saturday 13 Extended Weekend begins – 5:00 P.M.<br />
Tuesday 16 Extended Weekend ends – 7:30 P.M.<br />
Wednesday 17 Classes resume<br />
November<br />
Monday-Friday <strong>12</strong>-16 Fall Term Examinations<br />
Friday 16 Thanksgiving Recess begins – <strong>12</strong> NOON<br />
Monday 26 Thanksgiving Recess ends – 7:30 P.M.<br />
Tuesday 27 Classes resume<br />
December<br />
Wednesday 19 Winter Vacation begins – <strong>12</strong>:05 P.M.<br />
January<br />
Sunday 6 Winter Vacation ends – 7:30 P.M.<br />
Monday 7 Classes resume<br />
Thursday 31 Extended Weekend begins – <strong>12</strong>:05 P.M.<br />
February<br />
Monday 4 Extended Weekend ends – 7:30 P.M.<br />
Tuesday 5 Classes resume<br />
March<br />
Friday 1 Spring Vacation begins – <strong>12</strong>:05 P.M.<br />
Sunday 24 Spring Vacation ends – 7:30 P.M.<br />
Monday 25 Classes Resume<br />
April<br />
May<br />
Friday-Saturday 26 Spring Parents’ Weekend (Parents’ Association Auction on Friday)<br />
Saturday 27 Extended Weekend begins – 5:00 P.M.<br />
Monday 29 Extended Weekend ends – 7:30 P.M.<br />
Tuesday 30 Classes Resume<br />
Thursday 23 Reception for Seniors <strong>and</strong> Parents followed by Dinner – 5:<strong>15</strong> P.M.<br />
Thursday 23 Baccalaureate – 8:00 P.M.<br />
Friday 24 180th Commencement – 10:30 A.M.<br />
Sunday-Thursday 26-30 Spring Term Examinations for Grades 9-11<br />
Thursday 30 Close of School for Grades 9-11 – <strong>12</strong> NOON
suffield academy<br />
<strong>Suffield</strong>, Connecticut / 860.386.4400<br />
Dress Code Guidelines<br />
As published in the 2011-20<strong>12</strong> Student & Parent H<strong>and</strong>book*<br />
<strong>Suffield</strong> <strong>Academy</strong>’s dress code provides an essential element of a foundation for success. Students who enroll at <strong>Suffield</strong> should do so with the expectation that<br />
they will be asked to abide by the letter <strong>and</strong> the spirit of <strong>Suffield</strong>’s dress code. The letter of the dress code is embodied in the guidelines below.<br />
The intent of the dress code is to encourage appropriateness of dress for both boys <strong>and</strong> girls. Students should keep themselves clean <strong>and</strong> neat, <strong>and</strong> clothing<br />
should be in good repair. One key element of appropriateness is modesty in dress that is neither in bad taste nor distracting or revealing.<br />
Note: Boys’ <strong>and</strong> girls’ formal dress applies to clothing worn during the class day (Monday through Saturday) <strong>and</strong> within the academic buildings/quadrangle<br />
(south of Stiles Lane <strong>and</strong> west of Main Street).<br />
Boys’ Formal Dress<br />
• A sport jacket with buttons (no zippers) <strong>and</strong> a formal lapel (not collar) must be worn at all times, except during the month of September.<br />
• A tucked-in dress shirt <strong>and</strong> tie, a non-zippered turtleneck shirt/sweater, or mock turtleneck in good repair.<br />
• Dress slacks, corduroys or chinos with hidden tailored pockets <strong>and</strong> no frayed bottoms; a belt is required for boys.<br />
• Dress shoes <strong>and</strong> socks.<br />
Girls’ Formal Dress<br />
• 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 s<strong>and</strong>als.<br />
• 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<br />
dress shoes or styled s<strong>and</strong>als.<br />
• Dress slacks, corduroys, or chinos with hidden tailored pockets <strong>and</strong> no frayed bottoms accompanied by a woman’s blouse or woman’s dress shirt or<br />
turtleneck shirt/sweater.<br />
Note: A dress shirt does not include rugby shirts, tank tops, short or long-sleeved polo shirts, flannel shirts, or any shirt with writing.<br />
Shoes that attach only between the toes are not permitted.<br />
Saturday Morning Dress Code<br />
Students may choose between formal dress code <strong>and</strong> <strong>Suffield</strong> Spirit dress code from 8:00-11:<strong>15</strong> A.M. on Saturday mornings, except when otherwise stipulated.<br />
<strong>Suffield</strong> Spirit Dress includes the following—visible <strong>Suffield</strong> regalia (athletic jersey or <strong>Suffield</strong> <strong>Academy</strong> clothing from the school’s bookstore) above the waist in<br />
conjunction with formal dress for boys <strong>and</strong> girls. The intent of this dress code option is to encourage school spirit.<br />
*Dress code is subject to change. Please refer to the 20<strong>12</strong>-13 Student & Parent H<strong>and</strong>book when it becomes available in July 20<strong>12</strong>.
suffield academy<br />
<strong>Suffield</strong>, Connecticut / 860.386.4400<br />
STUDENT DEBIT ACCOUNT INFORMATION [page 1 of 3]<br />
All student charges <strong>and</strong> purchases other than tuition are made through the <strong>Suffield</strong> <strong>Academy</strong> Debit Card System. The <strong>Suffield</strong> <strong>Academy</strong> Debit Card is similar to a<br />
st<strong>and</strong>ard bank ATM card. While cash <strong>and</strong> checks are universally accepted for purchases <strong>and</strong> school charges, credit cards (Visa <strong>and</strong> MasterCard) are accepted in<br />
the <strong>Suffield</strong> <strong>Academy</strong> Bookstore.<br />
The <strong>Suffield</strong> <strong>Academy</strong> Debit Card is the preferred medium of exchange for student purchases at the School. Similar to an ATM card, purchases <strong>and</strong> withdrawals<br />
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 <strong>Suffield</strong> <strong>Academy</strong> Debit Card<br />
for school expenses <strong>and</strong> 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<br />
lost Debit Card. Your child’s Debit Card will be valid throughout his or her years at <strong>Suffield</strong> <strong>Academy</strong>. The card is required for all student purchases<br />
<strong>and</strong> withdrawals.<br />
Experience has shown that, with this system, students view the money in their account as their own <strong>and</strong>, for the most part, they demonstrate greater fiscal<br />
responsibility throughout the year than with open-ended charge privileges. This system will provide our students a valuable <strong>and</strong> realistic experience in h<strong>and</strong>ling<br />
money <strong>and</strong> will provide parents <strong>and</strong> guardians greater control over their child’s miscellaneous spending.<br />
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<br />
expense areas. We recommend weekly or monthly restrictions in the Cash Bank <strong>and</strong> Snack Bar categories. Other categories involve purchases that are essential<br />
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<br />
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<br />
having trouble managing expenditures, please let us k<strong>now</strong> <strong>and</strong> we can work with you to implement other controls <strong>and</strong> restrictions.<br />
An initial deposit, received before July <strong>15</strong>, 20<strong>12</strong>, is required to activate your child’s Debit Card account by the beginning of the school year. Additional deposits<br />
may be made at any time throughout the year by sending payments to the Business Office.<br />
Please fill out <strong>and</strong> return the Debit Card form with your initial deposit by July <strong>15</strong>, 20<strong>12</strong>. Your cooperation in meeting this deadline will greatly facilitate our ability<br />
to service your child’s needs in the opening days of school.<br />
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:<br />
<strong>Suffield</strong> <strong>Academy</strong> Business Office<br />
185 North Main Street<br />
<strong>Suffield</strong>, CT 06078<br />
Phone<br />
860-386-4455<br />
Fax<br />
860-668-2966<br />
Email<br />
pdellabernarda@suffieldacademy.org<br />
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FORM: DEBIT / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
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suffield academy<br />
<strong>Suffield</strong>, Connecticut / 860.386.4400<br />
STUDENT DEBIT ACCOUNT INFORMATION [page 2 of 3]<br />
EXPENSE CATEGORIES<br />
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<br />
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<br />
cash needs. Cash Bank allowance that is not drawn carries over <strong>and</strong> accumulates from week to week.<br />
2. BOOKSTORE: covers textbooks, school supplies, school clothing <strong>and</strong> logo memorabilia, phone cards, some personal toiletries <strong>and</strong> some athletic items.<br />
3. SNACK BAR: operated in the Student Union for the convenience of the students, it sells such items as soft drinks, juices, bagels, s<strong>and</strong>wiches <strong>and</strong><br />
ice cream.<br />
4. ATHLETICS: required <strong>and</strong> optional athletic equipment sold through the athletic department; also covers uniforms <strong>and</strong> equipment which are lost, destroyed<br />
or not returned at the end of a season.<br />
5. STUDENT ACTIVITIES: includes the cost of transportation <strong>and</strong> entrance fees for trips <strong>and</strong> activities organized by the School.<br />
6. ACADEMIC: includes charges for testing (SAT, PSAT, AP) fees, tutoring, art materials, <strong>and</strong> other academic needs.<br />
7. HEALTH CENTER: includes charges for health services, such as immunizations, diagnostic testing, prescription medications <strong>and</strong> transportation for medical<br />
visits to off-campus providers.<br />
8. MAINTENANCE: covers charges for replacing lost dorm keys <strong>and</strong> repairs for damage.<br />
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<br />
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.<br />
Permission to release funds will be accepted only from the student’s legal guardians.<br />
ESTIMATES AND RECOMMENDATIONS FOR SPENDING NEEDS AND LIMITS<br />
• 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).<br />
• Graphing calculators for upper level math courses cost in the $<strong>15</strong>0 range.<br />
• School sweatshirts cost about $40, other shirts range from $<strong>12</strong> to $30, hats cost about $<strong>15</strong>, outer wear can cost up to $70, computer software <strong>and</strong> hardware<br />
purchases are done by a special order arrangement.<br />
• Given the above three parameters of the Bookstore business, we suggest that you make an initial large deposit for school year startup.<br />
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<br />
additional funds are deposited into the account.<br />
[<br />
FORM: DEBIT / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
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[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
STUDENT DEBIT ACCOUNT INFORMATION [page 3 of 3]<br />
NAME OF STUDENT<br />
First Name Last Name Middle Name Year of Graduation<br />
Spending Restrictions: Please check the appropriate boxes<br />
Cash Bank<br />
Extraordinary Cash<br />
Bookstore<br />
Snack Bar<br />
Athletics<br />
Student Activities<br />
Academic<br />
Health Center<br />
Maintenance<br />
Unrestricted Use (maximum $50 per day)<br />
Weekly Allowance Amount<br />
(Note: Cash Bank allowance that is not drawn carries over <strong>and</strong> accumulates from week to week.)<br />
No Cash Withdrawal Allowed<br />
Restricted to parent/guardian confirmation for each request.<br />
Unrestricted Use<br />
Monthly Limit<br />
Only Cash/Check/Credit Card Purchases Allowed<br />
Unrestricted Use<br />
Weekly Limit<br />
Only Cash/Check Purchases Allowed<br />
Unrestricted<br />
Unrestricted<br />
Unrestricted<br />
Unrestricted<br />
Unrestricted<br />
Amount Enclosed<br />
(checks payable to <strong>Suffield</strong> <strong>Academy</strong>)<br />
Please provide address of person(s) responsible for Student Debit Card Account. Monthly Debit Card Account statements will be sent to this address:<br />
Name<br />
Street City State Zip Code<br />
Country<br />
Home Phone<br />
Email<br />
I/we underst<strong>and</strong> that the maintenance of a balance in this account is my/our responsibility <strong>and</strong> that <strong>Suffield</strong> <strong>Academy</strong> will not, without my/our request, advance<br />
funds to cover a transaction unless there is a sufficient balance in the account. Please print this form <strong>and</strong> send it along with payment to <strong>Suffield</strong> <strong>Academy</strong>,<br />
Attn. Patrick Booth, 185 North Main Street, <strong>Suffield</strong>, CT 06078.<br />
Parent or Guardian Name (please print <strong>and</strong> sign here if you intend to use a printed copy of this form)<br />
Date<br />
By checking this box <strong>and</strong> entering the student ID number above, you are signing this document electronically.<br />
[<br />
FORM: DEBIT / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
[
suffield academy<br />
<strong>Suffield</strong>, Connecticut / 860.386.4400<br />
HEALTH CENTER POLICIES<br />
Most of the routine services of the Health Center are covered by tuition. Our professional nurses evaluate students for common maladies; over-the-counter<br />
medications are provided for students with headaches, colds, minor injuries <strong>and</strong> illnesses; ace b<strong>and</strong>ages, crutches, ice packs, splints, <strong>and</strong> other similar supplies<br />
are also provided free of charge.<br />
Our medical director, Dr. Ross Porter, Board Certified in Pediatrics, comes to campus on Friday mornings <strong>and</strong> sees students who are ill or who need physicals,<br />
allergy injections, etc. The services of Dr. Porter <strong>and</strong> his associates are not covered by tuition. Please check with your insurance company to verify whether visits<br />
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<br />
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<br />
for any bills incurred from medical professionals while your child is at school is yours. If bills remain outst<strong>and</strong>ing for long periods of time, the <strong>Suffield</strong> <strong>Academy</strong><br />
Business Office will deduct payment from your child’s debit card account.<br />
Prescription medications are obtained from Partner RX Pharmacy in East Windsor, CT; Drug Shop in Enfield, CT; or CVS Pharmacy in <strong>Suffield</strong>. The pharmacy is<br />
given your insurance information <strong>and</strong> will bill the insurance company directly. Co-payments or full reimbursement for services will be billed to the family directly<br />
or deducted from your child’s debit account.<br />
The Health Center coordinates transportation, which is provided by hired drivers, for medical appointments scheduled off-campus. The cost for this<br />
transportation is $20 per hour <strong>and</strong> 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<br />
meet the driver at the scheduled time, unless the student notifies the Health Center at least two hours in advance.<br />
Flu vaccinations will be provided to your student if you desire. The cost of the vaccination is $25 <strong>and</strong> may be deducted from the student’s debit card account.<br />
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<br />
non-refundable.<br />
All narcotic <strong>and</strong> mood-altering prescription medications are kept in the Health Center <strong>and</strong> must be supplied in a blister pack from your pharmacy or from one<br />
of our local pharmacies. All medication must be in the original container from the pharmacy <strong>and</strong> labeled. Prescriptions that are self-administered must be<br />
accompanied by written instructions as to strength, dose <strong>and</strong> duration by the student’s physician. Prescriptions for controlled substance drugs <strong>and</strong> psychotropics<br />
must be kept at the Health Center <strong>and</strong> must be accompanied by the physician’s statement for administration.<br />
If you have questions regarding our financial or health care policies, please call Donna Rabbett, Director of Nursing at 860-386-4503 or<br />
email her at drabbett@suffieldacademy.org.
[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
Medical Insurance for <strong>Suffield</strong> <strong>Academy</strong> Students<br />
<strong>Suffield</strong> <strong>Academy</strong> requires that all enrolled students have insurance to cover emergency <strong>and</strong> other medical services that may be needed while they are at school.<br />
<strong>Suffield</strong> <strong>Academy</strong> offers an insurance package through the Student Insurance Division of the Mega Insurance Companies. This coverage is used by many<br />
independent schools, as well as colleges <strong>and</strong> universities. This <strong>Suffield</strong> <strong>Academy</strong> Insurance Plan is designed for students who do not have existing coverage. A<br />
brief description of the coverage follows this form. Your child will receive an identification card <strong>and</strong> full description of benefits if you enroll in the program for the<br />
20<strong>12</strong>-2013 school year. Our Health Center coordinates the interaction between health care providers <strong>and</strong> the insurance company.<br />
The premium cost for the plan offered is $1,720 <strong>and</strong> it covers the ten-month period from August <strong>15</strong>, 20<strong>12</strong>, through June 14, 2013.<br />
If you have any questions, you may call the Business Office at 860-668-73<strong>15</strong>, or email pbooth@suffieldacademy.org.<br />
If you already have medical insurance coverage that will cover your child’s expenses while at <strong>Suffield</strong> <strong>Academy</strong>, <strong>and</strong> you have provided written<br />
documentation of that coverage (attach a copy of your insurance card to the Permission for Medical or Surgical Treatment form, or scan <strong>and</strong> email your<br />
insurance card), please check Box A, sign <strong>and</strong> return this Waiver/Enrollment form. If you cannot provide such documentation, you will be required<br />
to purchase the <strong>Suffield</strong> <strong>Academy</strong> Insurance Plan coverage. In order to enroll your child in the insurance program at <strong>Suffield</strong>, please check Box B on<br />
this Waiver/Enrollment form, sign the form <strong>and</strong> return it with your check (in U.S. dollars).<br />
Student Health Insurance Waiver/Enrollment<br />
NAME OF STUDENT<br />
First Name last Name Middle Name<br />
Please choose either option A (Waiver) or B (Enrollment) <strong>and</strong> sign the form below<br />
A: WAIVER (If you have existing medical insurance coverage)<br />
As parent (guardian), I certify that the student listed above has medical insurance which will cover expenses incurred by illness or injury while attending<br />
<strong>Suffield</strong> <strong>Academy</strong>. I have provided a copy of the front <strong>and</strong> back of the insurance card, which will be on file in the <strong>Suffield</strong> <strong>Academy</strong> Health Center. I decline<br />
enrollment in the <strong>Suffield</strong> <strong>Academy</strong> Insurance Plan.<br />
B: ENROLLMENT<br />
If you do not have existing medical insurance for your child, you must enroll in <strong>Suffield</strong> <strong>Academy</strong> Insurance Plan. Premium cost is $1,720 (for coverage<br />
through June 14, 2013). Please enroll the above named student in the medical insurance program offered through <strong>Suffield</strong> <strong>Academy</strong>. I have enclosed<br />
payment in U.S. Dollars for the premium cost of the <strong>Suffield</strong> <strong>Academy</strong> Insurance Plan; I underst<strong>and</strong> that the coverage will begin August <strong>15</strong>, 20<strong>12</strong>, or<br />
when I pay the premium, whichever date is later. Please print this form <strong>and</strong> send it along with payment to <strong>Suffield</strong> <strong>Academy</strong>, Attn. Patrick Booth,<br />
185 North Main Street, <strong>Suffield</strong>, CT 06078.<br />
Parent or Guardian Name (please print <strong>and</strong> sign here if you intend to use a printed copy of this form)<br />
Date<br />
By checking this box <strong>and</strong> entering the student ID number above, you are signing this document electronically.<br />
[<br />
FORM: INSURANCE / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
[
20<strong>12</strong>-2013<br />
STUDENT INJURY AND SICKNESS<br />
INSURANCE PLAN<br />
Designed Especially for Students of<br />
<strong>Suffield</strong> <strong>Academy</strong><br />
Connecticut<br />
This Certificate does not provide coverage for:<br />
Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing,<br />
bungee jumping, or flight in any kind of aircraft, except while riding as a<br />
passenger on a regularly scheduled flight of a commercial airline.<br />
06-BR-CT (Rev 09) 06-1806-1
Table of Contents<br />
Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1<br />
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1<br />
Effective And Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1<br />
Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2<br />
Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2<br />
Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3<br />
Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5<br />
UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6<br />
M<strong>and</strong>ated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7<br />
Benefits for Accidental Ingestion of a Controlled Drug . . . . . . . . . . . . . . . . . . . . . . . . . .7<br />
Benefits for Hypodermic Needles or Syringes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7<br />
Benefits for Reconstructive Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8<br />
Benefits for Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8<br />
Benefits for Mammography <strong>and</strong> Comprehensive Ultrasound Screening . . . . . . . .9<br />
Benefits for Ostomy Appliances <strong>and</strong> Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9<br />
Benefits for Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9<br />
Benefits for Treatment of Tumors <strong>and</strong> Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10<br />
Benefits for Prostate Cancer Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10<br />
Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10<br />
Benefits for Cancer Clinical Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10<br />
Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10<br />
Benefits for Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11<br />
Benefits for Amino Acid Modified Preparations <strong>and</strong><br />
Low Protein Modified Food Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11<br />
Benefits for Lyme Disease Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11<br />
Benefits for Isolation Care <strong>and</strong> Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . .11<br />
Benefits for Diabetic Outpatient Self-Management Training . . . . . . . . . . . . . . . . . . .<strong>12</strong><br />
Benefits for Inpatient Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<strong>12</strong><br />
Benefits for Treatment of Craniofacial Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<strong>12</strong><br />
Benefits for Mental or Nervous Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<strong>12</strong><br />
Benefits for Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13<br />
Benefits for Infertility Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13<br />
Benefits for Epidermolysis Bullosa Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14<br />
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14<br />
Exclusions And Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14<br />
General Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16<br />
Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . .17<br />
Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back Cover
THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE<br />
COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR<br />
LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER<br />
ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO<br />
COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT<br />
CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR<br />
MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE<br />
COST OF SERVICES EXCEEDS THOSE LIMITS, THE INSURED<br />
AND NOT THE COMPANY IS RESPONSIBLE FOR PAYMENT OF<br />
THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE<br />
SPECIFIED IN THE SCHEDULE OF BENEFITS.<br />
Privacy Policy<br />
We k<strong>now</strong> that your privacy is important to you <strong>and</strong> we strive to protect the confidentiality of<br />
your nonpublic personal information. We do not disclose any nonpublic personal information<br />
about our customers or former customers to anyone, except as permitted or required by law.<br />
We believe we maintain appropriate physical, electronic <strong>and</strong> procedural safeguards to<br />
ensure the security of your nonpublic personal information. You may obtain a copy of our<br />
privacy practices by calling us toll-free at 800-767-0700 or by visiting us at www.uhcsr.com.<br />
Eligibility<br />
All Domestic students registered for credit courses are eligible to enroll in this insurance<br />
Plan.<br />
All International students registered for credit courses are automatically enrolled in this<br />
insurance Plan at registration, unless proof of comparable coverage is furnished.<br />
Students must actively attend classes for at least the first 31 days <strong>after</strong> the date for which<br />
coverage is purchased. The Company maintains its right to investigate student status <strong>and</strong><br />
attendance records to verify that the policy Eligibility requirements have been met. If the<br />
Company discovers the Eligibility requirements have not been met, its only obligation is to<br />
refund premium.<br />
Alternative Coverage - If you do not meet the Eligibility requirements of the Plan, please<br />
call 1-800-406-2338 for more information on alternative coverage. This information can<br />
also be accessed at http://www.goldenrulehealth.com/studentresources.<br />
Effective And Termination Dates<br />
The Master Policy on file at the school becomes effective at <strong>12</strong>:01 a.m., August <strong>15</strong>, 20<strong>12</strong>.<br />
Coverage becomes effective on the first day of the period for which premium is paid or the<br />
date the enrollment form <strong>and</strong> full premium are received by the Company (or its authorized<br />
representative), whichever is later. The Master Policy terminates at 11:59 p.m., June <strong>15</strong><br />
2013. Coverage terminates on that date or at the end of the period through which premium<br />
is paid, whichever is earlier.<br />
Refunds of premiums are allowed only upon entry into the armed forces.<br />
The Policy is a Non-Renewable One Year Term Policy.<br />
1
Extension of Benefits After Termination<br />
The coverage provided under the Policy ceases on the Termination Date. However, if an<br />
Insured is Totally Disabled on the Termination Date from a covered Injury or Sickness for<br />
which benefits were paid before the Termination Date, Covered Medical Expenses for such<br />
Injury or Sickness will continue to be paid as long as the condition continues but not to<br />
exceed 90 days <strong>after</strong> the Termination Date.<br />
The total payments made in respect of the Insured for such condition both before <strong>and</strong> <strong>after</strong><br />
the Termination Date will never exceed the Maximum Benefit.<br />
After this "Extension of Benefits" provision has been exhausted, all benefits cease to exist,<br />
<strong>and</strong> under no circumstances will further payments be made.<br />
Pre-Admission Notification<br />
UMR Care Management should be notified of all Hospital Confinements prior to admission.<br />
1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATION:<br />
The patient, Physician or Hospital should telephone 1-877-295-0720 at least five<br />
working days prior to the planned admission.<br />
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient,<br />
patient's representative, Physician or Hospital should telephone 1-877-295-0720<br />
within two working days of the admission to provide notification of any admission due<br />
to Medical Emergency.<br />
UMR Care Management is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00<br />
p.m. C.S.T., Monday through Friday. Calls may be left on the Customer Service Department's<br />
voice mail <strong>after</strong> hours by calling 1-877-295-0720.<br />
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise<br />
payable under the policy; however, pre-notification is not a guarantee that benefits will be<br />
paid.<br />
2
Schedule of Medical Expense Benefits<br />
Injury <strong>and</strong> Sickness<br />
Up to $250,000 Maximum Benefit (For each Injury or Sickness)<br />
Coinsurance 100%<br />
The policy provides benefits for 100% of Usual <strong>and</strong> Customary Charges incurred by an<br />
Insured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of<br />
$250,000 for each Injury or Sickness.<br />
Usual & Customary Charges are based on data provided by FAIR Health, Inc. using the<br />
90th percentile based on location of provider.<br />
Benefits will be paid up to the Maximum Benefit for each service as scheduled below.<br />
Covered Medical Expenses include:<br />
max = maximum<br />
INPATIENT<br />
U&C = Usual & Customary Charges<br />
Room & Board Expense, daily semi-private room rate; <strong>and</strong><br />
general nursing care provided by the Hospital.<br />
Hospital Miscellaneous Expenses, such as the cost of<br />
the operating room, laboratory tests, x-ray examinations,<br />
anesthesia, drugs (excluding take home drugs) or<br />
medicines, therapeutic services, <strong>and</strong> supplies. In computing<br />
the number of days payable under this benefit, the date of<br />
admission will be counted, but not the date of discharge.<br />
Intensive Care<br />
Physiotherapy<br />
Surgeon’s Fees, in accordance with data provided by<br />
FAIR Health, Inc. If two or more procedures are performed<br />
through the same incision or in immediate succession at<br />
the same operative session, the maximum amount paid will<br />
not exceed 50% of the second procedure <strong>and</strong> 50% of all<br />
subsequent procedures.<br />
Assistant Surgeon<br />
Anesthetist, professional services administered in<br />
connection with inpatient surgery.<br />
Registered Nurse’s Services, private duty nursing care.<br />
Physician’s Visits, benefits are limited to one visit per day<br />
<strong>and</strong> do not apply when related to surgery.<br />
Pre-Admission Testing, payable within 7 working days<br />
prior to admission.<br />
Mental or Nervous Conditions<br />
U&C<br />
U&C<br />
U&C<br />
U&C<br />
U&C<br />
30% of Surgery Allowance<br />
U&C<br />
U&C<br />
U&C<br />
U&C<br />
Paid as any other Sickness<br />
3
OUTPATIENT<br />
Surgeon’s Fees, in accordance with data provided by FAIR<br />
Health, Inc. If two or more procedures are performed<br />
through the same incision or in immediate succession at the<br />
same operative session, the maximum amount paid will not<br />
exceed 50% of the second procedure <strong>and</strong> 50% of all<br />
subsequent procedures.<br />
Day Surgery Miscellaneous, related to scheduled surgery<br />
performed in a Hospital, including the cost of the operating<br />
room; laboratory tests <strong>and</strong> x-ray examinations, including<br />
professional fees; anesthesia; drugs or medicines; <strong>and</strong><br />
supplies. Usual <strong>and</strong> Customary Charges for Day Surgery<br />
Miscellaneous are based on the Outpatient Surgical Facility<br />
Charge Index.<br />
Assistant Surgeon<br />
U&C<br />
U&C<br />
Anesthetist, professional services administered in U&C<br />
connection with outpatient surgery.<br />
Physician’s Visits, benefits are limited to one visit per day. U&C<br />
Benefits for Physician’s Visits do not apply when related to<br />
surgery or Physiotherapy.<br />
Physiotherapy/ Occupational Therapy, benefits are<br />
limited to one visit per day. Review of Medical Necessity will<br />
be performed <strong>after</strong> <strong>12</strong> visits per Injury or Sickness.<br />
Medical Emergency Expenses, use of the emergency<br />
room <strong>and</strong> supplies. Treatment must be rendered within 72<br />
hours from time of Injury or first onset of Sickness.<br />
Diagnostic X-ray & Laboratory Services<br />
Radiation Therapy<br />
Chemotherapy<br />
Tests & Procedures, diagnostic services <strong>and</strong> medical<br />
procedures performed by a Physician, other than Physician’s<br />
Visits, Physiotherapy, X-Rays <strong>and</strong> Lab Procedures.<br />
Injections, when administered in the Physician’s office <strong>and</strong><br />
charged on the Physician’s statement.<br />
Prescription Drugs, UnitedHealthcare Network Pharmacy,<br />
$0 copay per prescription tier 1, tier 2, tier 3 / up to a 31 day<br />
supply per prescription. Out-of-Network prescription drugs<br />
paid at 100% actual billed charges, $0 Deductible per<br />
prescription up to a 31 day supply, $1,500 maximum Per<br />
Policy Year combined in <strong>and</strong> out of network. Diabetic insulin<br />
<strong>and</strong> supplies are not subject to the $1,500 prescription drug<br />
maximum benefit. See Benefits for Diabetes.<br />
30% of Surgery Allowance<br />
U&C<br />
U&C<br />
U&C<br />
U&C<br />
U&C<br />
U&C<br />
U&C<br />
$1,500 max<br />
(Per Policy Year)<br />
Mental or Nervous Conditions<br />
Paid as any other Sickness<br />
4
OTHER<br />
Ambulance Services, when medically necessary transport<br />
to a Hospital.<br />
Durable Medical Equipment, a written prescription must<br />
accompany the claim when submitted. Replacement<br />
equipment is not covered.<br />
5<br />
Maximum allowable rate<br />
established by the<br />
Department of Public<br />
Health<br />
U&C<br />
Alcoholism / Drug Abuse<br />
See Benefit for Treatment<br />
of Mental or Nervous<br />
Conditions<br />
Consultant Physician Fees, when requested <strong>and</strong> U&C<br />
approved by the attending Physician.<br />
Dental Treatment, made necessary by Injury to Sound, U&C<br />
Natural Teeth; Exception: See Benefits for In-patient Dental<br />
Services.<br />
Maternity & Complications of Pregnancy<br />
Paid as any other Sickness<br />
Interscholastic Sports<br />
Paid as any other Injury<br />
Eating Disorders<br />
Home Health Care<br />
Preventive Care, Preventive Care benefits are based on<br />
guidelines from UnitedHealthcare, the U.S. Preventive<br />
Services Task Force <strong>and</strong> recommendations of the National<br />
Immunizations Program of the Centers for Disease Control<br />
Prevention, except as specifically provided in the M<strong>and</strong>ated<br />
Benefit.<br />
U&C / $5,000 max<br />
See Benefits for Home<br />
Health Care<br />
U&C<br />
Urgent Care Clinic Fee, Benefits are limited to the Urgent U&C<br />
Care Clinic fee billed by the Urgent Care Clinic/Hospital. All<br />
other services rendered during the visit are payable as<br />
specified in the Schedule of Benefits.<br />
Maternity Testing<br />
This policy does not cover routine, preventive or screening examinations or testing unless<br />
Medical Necessity is established based on medical records. The following maternity routine<br />
tests <strong>and</strong> screening exams will be considered if all other policy provisions have been met:<br />
Initial screening at first visit – Pregnancy test: Urine human chorionic gonatropin (HCG),<br />
Asymptomatic bacteriuria: Urine culture, Blood type <strong>and</strong> Rh antibody, Rubella, Pregnancyassociated<br />
plasma protein-A (PAPPA) (first trimester only), Free beta human chorionic<br />
gonadotrophin (hCG) (first trimester only), Hepatitis B: HBsAg, Pap smear, Gonorrhea: Gc<br />
culture, Chlamydia: chlamydia culture, Syphilis: RPR, HIV: HIV-ab, <strong>and</strong> Coombs test; Each<br />
visit – Urine analysis; Once every trimester – Hematocrit <strong>and</strong> Hemoglobin; Once during<br />
first trimester – Ultrasound; Once during second trimester – Ultrasound (anatomy<br />
scan); Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein<br />
(AFP), Estriol, hCG, inhibin-a; Once during second trimester if age 35 or over -<br />
Amniocentesis or Chorionic villus sampling (CVS); Once during second or third<br />
trimester – 50g Glucola (blood glucose 1 hour postpr<strong>and</strong>ial); <strong>and</strong> Once during third<br />
trimester - Group B Strep Culture. Pre-natal vitamins are not covered. For additional<br />
information regarding Maternity Testing, please call the Company at 1-800-767-0700.
UnitedHealthcare Network Pharmacy Benefits<br />
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)<br />
when dispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supply<br />
limits <strong>and</strong> copayments that vary depending on which tier of the PDL the outpatient drug is<br />
listed. There are certain Prescription Drugs that require your Physician to notify us to verify<br />
their use is covered within your benefit.<br />
Prescription Drugs which require notification are:<br />
Actiq, Anzemet, Avita-Penderm, Avodart, Copegus, Differin-Gladerma, Diflucan, Elidel,<br />
Emend, Genotropin, Humatrope, Increlex, Infergen, Intron-A, Iplex, Kytril, Lamisil, Lotronex,<br />
Norditropin, Nutropin, Nutropin AQ, Nutropin Depot, PEG-Intron, Pegasys, Proscar, Protopic,<br />
Protropin, Provigil, Raptiva, Regranex, Relenza, Retin-A, Retin-A Micro Ortho, Rebetol,<br />
Rebetron, Restasis, Revatio, Roferon, Sporanox, Saizen, Serostim, Tamiflu, Tazorac, Tracleer,<br />
Ventavis, Wellbutrin SR, Wellbutrin XL, Zelnorm, Zofran, Zorbtive.<br />
You are responsible for paying the applicable copayments. Your copayment is determined<br />
by the tier to which the Prescription Drug Product is assigned on the PDL. Tier status may<br />
change periodically <strong>and</strong> without prior notice to you. Please call 877-417-7345 for the most<br />
up-to-date tier status.<br />
$0 copay per prescription or refill for tier 1 Prescription Drug up to 31 day supply.<br />
$0 copay per prescription or refill for tier 2 Prescription Drug up to 31 day supply.<br />
$0 copay per prescription or refill for tier 3 Prescription Drug up to 31 day supply.<br />
Your maximum allowed benefit is $1,500 Per Policy Year.<br />
Diabetic insulin <strong>and</strong> supplies are not subject to the $1,500 Prescription Drugs maximum<br />
benefit but are subject to the overall Policy Maximum Benefit.<br />
Please present your ID card to the network pharmacy when the prescription is filled. If you<br />
do not present the card, you will need to pay for the prescription <strong>and</strong> then submit a<br />
reimbursement form for prescriptions filled at a network pharmacy along with the paid<br />
receipt in order to be reimbursed. To obtain reimbursement forms, or for information about<br />
mail-order prescriptions or network pharmacies, please visit www.uhcsr.com <strong>and</strong> log in to<br />
your online account or call 877-417-7345.<br />
When prescriptions are filled at pharmacies outside the network, the Insured must pay for<br />
the prescriptions out-of-pocket <strong>and</strong> submit the receipts for reimbursement to<br />
UnitedHealthcare StudentResources, P.O. Box 809025, Dallas, TX 75380-9025. See the<br />
Schedule of Benefits for the benefits payable at out-of-network pharmacies.<br />
Additional Exclusions<br />
In addition to the policy Exclusions <strong>and</strong> Limitations, the following Exclusions apply to<br />
Network Pharmacy Benefits:<br />
1. Coverage for Prescription Drug Products for the amount dispensed (days' supply or<br />
quantity limit) which exceeds the supply limit.<br />
2. Experimental or Investigational Services or Unproven Services <strong>and</strong> medications;<br />
medications used for experimental indications <strong>and</strong>/or dosage regimens determined<br />
by the Company to be experimental, investigational or unproven.<br />
3. Compounded drugs that do not contain at least one ingredient that has been<br />
approved by the U.S. Food <strong>and</strong> Drug Administration <strong>and</strong> requires a Prescription <strong>Order</strong><br />
or Refill. Compounded drugs that are available as a similar commercially available<br />
Prescription Drug Product. Compounded drugs that contain at least one ingredient<br />
that requires a Prescription <strong>Order</strong> or Refill are assigned to Tier-3.<br />
6
4. Drugs available over-the-counter that do not require a Prescription <strong>Order</strong> or Refill by<br />
federal or state law before being dispensed, unless the Company has designated the<br />
over-the counter medication as eligible for coverage as if it were a Prescription Drug<br />
Product <strong>and</strong> it is obtained with a Prescription <strong>Order</strong> or Refill from a Physician.<br />
Prescription Drug Products that are available in over-the-counter form or comprised<br />
of components that are available in over-the-counter form or equivalent, unless a<br />
Medical Necessity. Certain Prescription Drug Products that the Company has<br />
determined are Therapeutically Equivalent to an over-the-counter drug, unless<br />
Medical Necessity. Such determinations may be made up to six times during a<br />
calendar year, <strong>and</strong> the Company may decide at any time to reinstate Benefits for a<br />
Prescription Drug Product that was previously excluded under this provision.<br />
5. Any product for which the primary use is a source of nutrition, nutritional supplements,<br />
or dietary management of disease, even when used for the treatment of Sickness or<br />
Injury, except as required by state m<strong>and</strong>ate.<br />
Definitions:<br />
Network Pharmacy means a pharmacy that has:<br />
• Entered into an agreement with the Company or an organization contracting on our<br />
behalf to provide Prescription Drug Products to Insured Persons.<br />
• Agreed to accept specified reimbursement rates for dispensing Prescription Drug<br />
Products.<br />
• Been designated by the Company as a Network Pharmacy.<br />
Prescription Drug or Prescription Drug Product means a medication, product or device<br />
that has been approved by the U.S. Food <strong>and</strong> Drug Administration <strong>and</strong> that can, under<br />
federal or state law, be dispensed only pursuant to a Prescription <strong>Order</strong> or Refill. A<br />
Prescription Drug Product includes a medication that, due to its characteristics, is<br />
appropriate for self-administration or administration by a non-skilled caregiver. For the<br />
purpose of the benefits under the policy, this definition includes insulin.<br />
Prescription Drug List means a list that categorizes into tiers medications, products or<br />
devices that have been approved by the U.S. Food <strong>and</strong> Drug Administration. This list is<br />
subject to the Company’s periodic review <strong>and</strong> modification (generally quarterly, but no more<br />
than six times per calendar year). The Insured may determine to which tier a particular<br />
Prescription Drug Product has been assigned through the Internet at www.uhcsr.com or call<br />
Customer Service at 1-877-417-7345.<br />
M<strong>and</strong>ated Benefits<br />
Benefits for Accidental Ingestion of a Controlled Drug<br />
Benefits will be paid for accidental ingestion or consumption of a controlled drug as<br />
required by Connecticut statute. When inpatient treatment in a Hospital, whether or not<br />
operated by the State, is required as a result of accidental ingestion or consumption of a<br />
controlled drug, benefits will be paid for the Usual <strong>and</strong> Customary Charges incurred up to<br />
a maximum of 30 days Hospital Confinement. Benefits will be paid for outpatient treatment<br />
resulting from accidental ingestion or consumption of a controlled drug up to a maximum<br />
of $500 for any one accident.<br />
Benefits for Hypodermic Needles or Syringes<br />
Benefits will be paid for the Usual <strong>and</strong> Customary Charges incurred for hypodermic needles<br />
or syringes prescribed by a licensed Physician for the purpose of administering medications<br />
for any Injury or Sickness, provided such medications are covered under the policy.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
7
Benefits for Reconstructive Breast Surgery<br />
Benefits will be paid for the Usual <strong>and</strong> Customary Charges incurred for reconstructive<br />
surgery on each breast on which a mastectomy has been performed, <strong>and</strong> reconstructive<br />
surgery on a nondiseased breast to produce a symmetrical appearance. Reconstructive<br />
surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty<br />
<strong>and</strong> mastopexy.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Home Health Care<br />
Benefits will be paid as specified below for Injury or Sickness for home health care to<br />
residents in Connecticut.<br />
Benefits payable shall be limited to eighty visits in any calendar year or in any continuous<br />
period of twelve months for each Insured, except in the case of an Insured diagnosed by a<br />
Physician as terminally ill with a prognosis of six months or less to live, the yearly benefit for<br />
medical social services shall not exceed two hundred dollars ($200.00). Each visit by a<br />
representative of a home health agency shall be considered as one home health care visit;<br />
four hours of home health aide service shall be considered as one home health care visit.<br />
Home health care benefits are subject to an annual Deductible of fifty dollars ($50.00) for<br />
each Insured <strong>and</strong> will be subject to a coinsurance provision of not less than seventy-five<br />
percent (75%) of the Usual <strong>and</strong> Customary Charges for such services. If an Insured is<br />
eligible for home health care coverage under more than one policy, the home health care<br />
benefits shall only be provided by that Policy which would have provided the greatest<br />
benefits for hospitalization if the person had remained or had been hospitalized.<br />
"Home health care" means the continued care <strong>and</strong> treatment of a covered person who is<br />
under the care of a Physician if:<br />
(1) continued hospitalization would otherwise have been required if home health care was<br />
not provided, except in the case of an Insured diagnosed by a Physician as terminally<br />
ill with a prognosis of six months or less to live, <strong>and</strong>,<br />
(2) the plan covering the home health care is established <strong>and</strong> approved in writing by such<br />
Physician within seven days following termination of a hospital confinement as a<br />
resident inpatient for the same or a related condition for which the Insured was<br />
hospitalized, except that in the case of an Insured diagnosed by a Physician as<br />
terminally ill with a prognosis of six months or less to live, such plan may be so<br />
established <strong>and</strong> approved at any time irrespective of whether such Insured was so<br />
confined or, if such Insured was so confined, irrespective of such seven-day period,<br />
<strong>and</strong><br />
(3) such home health care is commenced within seven days following discharge, except<br />
in the case of a covered person diagnosed by a Physician as terminally ill with a<br />
prognosis of six months or less to live.<br />
Home health care shall be provided by a home health agency. "Home health agency"<br />
means an agency or organization which meets each of the following requirements:<br />
(1) It is primarily engaged in <strong>and</strong> is federally certified as a home health agency <strong>and</strong> duly<br />
licensed by the appropriate licensing authority to provide nursing <strong>and</strong> other<br />
therapeutic services.<br />
(2) Its policies are established by a professional group associated with such agency or<br />
organization, including at least one Physician <strong>and</strong> at least one Registered Nurse, to<br />
govern the services provided.<br />
(3) It provides for full-time supervision of such services by a Physician or by a Registered<br />
Nurse.<br />
(4) It maintains a complete medical record on each patient.<br />
(5) It has an administrator.<br />
8
Home health care shall consist of, but shall not be limited to, the following:<br />
(1) Part-time or intermittent nursing care by a Registered Nurse or by a licensed practical<br />
nurse under the supervision of a Registered Nurse, if the services of a Registered<br />
Nurse are not available;<br />
(2) Part-time or intermittent home health aide services, consisting primarily of patient care<br />
of a medical or therapeutic nature by other than a Registered Nurse or licensed<br />
practical nurse;<br />
(3) Physical, occupational or speech therapy;<br />
(4) Medical supplies, drugs <strong>and</strong> medicines prescribed by a Physician <strong>and</strong> laboratory<br />
services to the extent such charges would have been covered under the Policy or<br />
contract if the Insured had remained or had been confined in the Hospital;<br />
(5) Medical social services provided to or for the benefit of a covered person diagnosed<br />
by a Physician as terminally ill with a prognosis of six months or less to live. "Medical<br />
social services" mean services rendered, under the direction of a Physician by a<br />
qualified social worker, including but not limited to:<br />
(A) assessment of the social, psychological <strong>and</strong> family problems related to or arising out<br />
of such covered person's illness <strong>and</strong> treatment;<br />
(B)appropriate action <strong>and</strong> utilization of community resources to assist in resolving such<br />
problems;<br />
(C)participation in the development of the overall plan of treatment for such Insured.<br />
Benefits shall be subject to all other limitations <strong>and</strong> provisions of the policy.<br />
Benefits for Mammography <strong>and</strong> Comprehensive Ultrasound Screening<br />
Benefits will be paid the same as any other Covered Medical Expenses as shown on the<br />
Schedule of Benefits for mammographic examinations to any woman insured under this<br />
policy which are equal to the following requirements: 1) a baseline mammogram for any<br />
woman who is thirty-five to thirty-nine years of age, inclusive; <strong>and</strong> 2) a mammogram every<br />
year for any woman who is forty years of age or older.<br />
Additional benefits will be provided for comprehensive ultrasound screening of an entire<br />
breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue<br />
based on the Breast Imaging Reporting <strong>and</strong> Data System established by the American<br />
College of Radiology or if a woman is believed to be at increased risk for breast cancer due<br />
to family history or prior personal history of breast cancer, positive genetic testing or other<br />
indications as determined by a woman’s Physician or advanced practice Registered Nurse.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Ostomy Appliances <strong>and</strong> Supplies<br />
Benefits will be paid for the Usual <strong>and</strong> Customary Charges for Medically Necessary<br />
appliances <strong>and</strong> supplies relating to an ostomy including, but not limited to, collection<br />
devices, irrigation equipment <strong>and</strong> supplies, skin barriers <strong>and</strong> skin protectors up to a<br />
maximum benefit of $1,000 per Policy Year.<br />
"Ostomy" shall include colostomy, ileostomy <strong>and</strong> urostomy.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Autism Spectrum Disorders<br />
Benefits will be paid the same as any other Sickness for physical therapy, speech therapy,<br />
<strong>and</strong> occupational therapy services for the treatment of Autism Spectrum Disorders, as set<br />
forth in the most recent edition of the American Psychiatric Association’s “Diagnostic <strong>and</strong><br />
Statistical Manual of Mental Disorders”.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
9
Benefits for Treatment of Tumors <strong>and</strong> Leukemia<br />
Benefits will be paid the same as any other Sickness for the surgical removal of tumors <strong>and</strong><br />
for treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, cost<br />
of any non-dental prosthesis, including any maxillofacial prosthesis used to replace<br />
anatomic structures lost during treatment for head <strong>and</strong> neck tumors or additional<br />
appliances essential for the support of such prosthesis <strong>and</strong> outpatient chemotherapy<br />
following surgical procedures in connection with the treatment of tumors, <strong>and</strong> a wig if<br />
prescribed by a licensed oncologist for a patient who suffers hair loss as a result of<br />
chemotherapy.<br />
Benefits per policy year shall be at least $1,000 for the removal of any breast implant,<br />
$500 for the surgical removal of tumors, $500 for reconstructive surgery, $500 for<br />
outpatient chemotherapy <strong>and</strong> $300 for prosthesis, except that for purposes of the surgical<br />
removal of breasts due to tumors the yearly benefit for prosthesis shall be at least $300 for<br />
each breast removed, <strong>and</strong> $350 for a wig.<br />
If the policy provides benefits for Prescription Drugs, benefits will be provided for prescribed<br />
orally administered anticancer medications on a basis that is no less favorable than<br />
intravenously administered anticancer medications.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Prostate Cancer Testing<br />
Benefits will be paid the same as any other Sickness for laboratory <strong>and</strong> diagnostic tests,<br />
including, but not limited to, prostate specific antigen (PSA) tests to screen for prostate<br />
cancer for Insureds who are symptomatic, whose biological father or brother has been<br />
diagnosed with prostate cancer, <strong>and</strong> for all Insureds fifty (50) years of age or older.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Colorectal Cancer Screening<br />
Benefits will be paid the same as any other Sickness for colorectal cancer screening,<br />
including, but not limited to: (1) an annual fecal occult blood test, <strong>and</strong> (2) colonoscopy,<br />
flexible sigmoidoscopy or radiologic imaging, in accordance with the recommendations<br />
established by the American College of Gastroenterology, <strong>after</strong> their consultation with the<br />
American Cancer Society, based on the ages, family histories <strong>and</strong> frequencies provided in<br />
the recommendations.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Cancer Clinical Trial<br />
Benefits will be paid the same as any other Sickness for the medically necessary treatment<br />
for Routine Patient Care Costs associated with Cancer Clinical Trials.<br />
Benefits are subject to all Deductible, copayment, terms, conditions, restrictions, Exclusions<br />
<strong>and</strong> Limitations of the policy.<br />
A detailed description of the benefits <strong>and</strong> restrictions for Cancer Clinical Trials is available<br />
in the Master Policy on file at the school or by calling the Company at 1-800-767-0700.<br />
Benefits for Diabetes<br />
Benefits will be paid the same as any other Sickness for the treatment of insulin-dependent<br />
diabetes, insulin-using diabetes, gestational diabetes <strong>and</strong> non-insulin-using diabetes. Such<br />
coverage shall include Medically Necessary equipment, in accordance with the Insured<br />
Person's treatment plan, drugs <strong>and</strong> supplies prescribed by a Physician.<br />
If the policy contains a Prescription Drugs maximum benefit, diabetic insulin <strong>and</strong> supplies<br />
shall not be subject to the Prescription Drugs maximum benefit specified in the Schedule<br />
of Benefits. Benefits shall be subject to all other Deductible, copayments, coinsurance,<br />
limitations, or any other provisions of the policy.<br />
10
Benefits for Postpartum Care<br />
If an Insured <strong>and</strong> Newborn Infant are discharged from inpatient care less than forty-eight<br />
hours <strong>after</strong> a vaginal delivery or less than ninety-six hours <strong>after</strong> a cesarean delivery, benefits<br />
will be provided on the same basis as any other Covered Medical Expenses as shown on<br />
the Schedule of Benefits for a follow-up visit within forty-eight hours of discharge <strong>and</strong> an<br />
additional follow-up visit within seven days of discharge. Any decision to shorten the length<br />
of inpatient stay to less than forty-eight hours <strong>after</strong> a vaginal delivery or ninety-six hours<br />
<strong>after</strong> a cesarean delivery shall be made by the Physician <strong>after</strong> conferring with the Insured.<br />
Follow-up services shall include, but not be limited to, physical assessment of the Newborn,<br />
parent education, assistance <strong>and</strong> training in breast or bottle feeding, assessment of the<br />
home support system <strong>and</strong> the performance of any Medically Necessary <strong>and</strong> appropriate<br />
clinical tests. Such services shall be consistent with protocols <strong>and</strong> guidelines developed by<br />
attending providers or by national pediatric, obstetric <strong>and</strong> nursing professional organizations<br />
for these services <strong>and</strong> shall be provided by qualified health care personnel trained in<br />
postpartum maternal <strong>and</strong> Newborn pediatric care.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Amino Acid Modified Preparations <strong>and</strong><br />
Low Protein Modified Food Products<br />
Benefits will be paid the same as any other outpatient Prescription Drug for Amino Acid<br />
Modified Preparations <strong>and</strong> Low Protein Modified Food Products for the treatment of<br />
Inherited Metabolic Diseases if the Amino Acid Modified Preparations or Low Protein<br />
Modified Food Products are prescribed for the therapeutic treatment of Inherited Metabolic<br />
Diseases <strong>and</strong> are administered under the direction of a Physician.<br />
If the policy does not provide benefits for outpatient Prescription Drugs, benefits will be<br />
provided subject to the policy maximum benefit including any Deductible, copayment or<br />
coinsurance requirements.<br />
"Inherited metabolic disease" means (A) disease for which newborn screening is required<br />
under Connecticut Statute Title 38a, Chapter 700c, Section 19a-55, <strong>and</strong> (B) Cystic Fibrosis.<br />
"Low protein modified food product: means a product formulated to have less than one<br />
gram of protein per serving <strong>and</strong> intended for the dietary treatment of an inherited metabolic<br />
disease under the direction of a physician.<br />
"Amino acid modified preparation" means a product intended for the dietary treatment of<br />
an inherited metabolic disease under the direction of a Physician.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Lyme Disease Treatment<br />
Benefits will be paid the same as any other Sickness for Lyme disease treatment including<br />
not less than thirty days of intravenous antibiotic therapy, sixty days of oral antibiotic therapy,<br />
or both, <strong>and</strong> shall provide benefits for further treatment if recommended by a Physician.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Isolation Care <strong>and</strong> Emergency Services<br />
Benefits will be paid the same as any other Injury or Sickness for isolation care <strong>and</strong><br />
emergency services provided by the state’s mobile field Hospital.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
11
Benefits for Diabetic Outpatient Self-Management Training<br />
Benefits will be paid the same as any other Sickness for outpatient self-management<br />
training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational<br />
diabetes <strong>and</strong> non-insulin-using diabetes if the training is prescribed by a Physician.<br />
Outpatient self-management training includes, but is not limited to, education <strong>and</strong> medical<br />
nutrition therapy. Diabetes self-management training shall be provided by a Physician, as<br />
defined in the Policy, trained in the care <strong>and</strong> management of diabetes <strong>and</strong> authorized to<br />
provide such care within the scope of the Physician's practice.<br />
Covered Medical Expenses shall include:<br />
1) Initial training visits provided to an Insured <strong>after</strong> the Insured is initially diagnosed<br />
with diabetes that is Medically Necessary for the care <strong>and</strong> management of diabetes,<br />
including, but not limited to, counseling in nutrition <strong>and</strong> the proper use of equipment<br />
<strong>and</strong> supplies for the treatment of diabetes, up to a maximum of ten hours.<br />
2) Training <strong>and</strong> education that is Medically Necessary as a result of a subsequent<br />
diagnosis by a Physician of a significant change in the Insured's symptoms or<br />
condition which requires modification of the Insured's program of self-management<br />
of diabetes, up to a maximum of four hours.<br />
3) Training <strong>and</strong> education that is Medically Necessary because of the development of<br />
new techniques <strong>and</strong> treatment for diabetes up to a maximum of four hours.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Inpatient Dental Services<br />
Benefits will be paid the same as any other Sickness for general anesthesia, nursing <strong>and</strong><br />
related Hospital services provided in conjunction with inpatient, outpatient or one day dental<br />
services if the following conditions are met:<br />
1) The anesthesia, nursing <strong>and</strong> related Hospital services are deemed Medically<br />
Necessary by the treating Physician.<br />
2) The Insured is either a) a person who is determined by a Physician to have a dental<br />
condition of significant dental complexity that it requires certain dental procedures<br />
to be performed in a Hospital, or b) a person who has a developmental disability, as<br />
determined by a Physician, that places the person at serious risk.<br />
The expense of anesthesia, nursing <strong>and</strong> related Hospital services shall be deemed a<br />
Covered Medical Expense <strong>and</strong> shall not be subject to any limits on dental benefits in the<br />
Policy.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Treatment of Craniofacial Disorders<br />
Benefits will be paid the same as any other Sickness for medically necessary orthodontic<br />
processes <strong>and</strong> appliances for the treatment of craniofacial disorders for Insureds eighteen<br />
years of age or younger. The processes <strong>and</strong> appliances must be prescribed by a craniofacial<br />
team recognized by the American Cleft Palate-Craniofacial Association. No benefits are<br />
provided for cosmetic surgery.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Mental or Nervous Conditions<br />
Benefits will be paid the same as any other Sickness for the diagnosis <strong>and</strong> treatment of<br />
Mental or Nervous Conditions.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
<strong>12</strong>
Benefits for Pain Management<br />
Benefits will be paid the same as any other Sickness for Pain treatment ordered by a Pain<br />
Management Specialist, which may include all means Medically Necessary to make a<br />
diagnosis <strong>and</strong> develop a treatment plan including the use of necessary medications <strong>and</strong><br />
procedures.<br />
"Pain" means a sensation in which a person experiences severe discomfort, distress or<br />
suffering due to provocation of sensory nerves, <strong>and</strong> "pain management specialist" means a<br />
Physician who is credentialed by the American <strong>Academy</strong> of Pain Management or who is a<br />
board-certified anesthesiologist, neurologist, oncologist or radiation oncologist with<br />
additional training in pain management.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Benefits for Infertility Treatment<br />
Benefits will be paid the same as any other Sickness for an Insured Person for the<br />
medically necessary expenses of the diagnosis <strong>and</strong> treatment of Infertility, including, but not<br />
limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo<br />
lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer <strong>and</strong><br />
low tubal ovum transfer. Such infertility treatment must be performed at facilities that<br />
conform to the st<strong>and</strong>ards <strong>and</strong> guidelines developed by the American Society of<br />
Reproductive Medicine or the Society of Reproductive Endocrinology <strong>and</strong> Infertility.<br />
For the purposes of this section “Infertility” means the condition of a presumably healthy<br />
individual who is unable to conceive or produce conception or sustain a successful<br />
pregnancy during a one year period.<br />
Benefits are subject to the following limitations:<br />
1) Benefits are available up to the Insured Person’s fortieth (40) birthday.<br />
2) Benefits for ovulation induction are subject to a lifetime limit of four (4) cycles.<br />
3) Benefits for intrauterine insemination are subject to a lifetime limit of three (3) cycles.<br />
4) Benefits for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian<br />
transfer, <strong>and</strong> tubal ovum transfer are subject to a lifetime limit of two (2) cycles, with<br />
not more than two (2) embryo implantations per cycle.<br />
5) Benefits for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian<br />
transfer <strong>and</strong> low tubal ovum transfer are payable only to those Insured Persons who:<br />
a) Have been unable to conceive or produce conception or sustain a successful<br />
pregnancy through less expensive <strong>and</strong> medically viable infertility treatment or<br />
procedures covered by this policy. However benefits will not be denied on this basis<br />
for any Insured Person who forgoes a particular infertility treatment or procedure if<br />
the Insured Person’s Physician determines that such treatment or procedure is<br />
likely to be unsuccessful.<br />
b) Have been covered under the school’s student insurance policy for at least <strong>12</strong><br />
months.<br />
c) Provide disclosure of any previous infertility treatment or procedures for which such<br />
Insured Person received coverage under a different health insurance policy.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
13
Benefits for Epidermolysis Bullosa Treatment<br />
Benefits will be paid for the Usual <strong>and</strong> Customary Charges for wound-care supplies that<br />
are Medically Necessary for the treatment of Epidermolysis Bullosa provided such benefits<br />
are administered under the direction of a Physician.<br />
“Epidermolysis Bullosa” is a genetic disorder caused by a mutation in the keratin gene. The<br />
disorder is characterized by the presence of extremely fragile skin <strong>and</strong> recurrent blister<br />
formation, resulting from minor mechanical friction or trauma.<br />
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or any<br />
other provisions of the policy.<br />
Definitions<br />
Injury means accidental bodily injuries sustained by the Insured Person which: 1) are the<br />
direct cause, independent of disease or bodily infirmity or any other cause; 2) are treated<br />
by a Physician within 30 days <strong>after</strong> the date of accident; <strong>and</strong> occurs while this policy is in<br />
force, subject to the policy Pre-existing Condition provisions. Covered Medical Expenses<br />
incurred as a result of an injury that occurred prior to this policy's Effective Date will be<br />
considered a Sickness under this policy, subject to the policy Pre-existing Condition<br />
provisions.<br />
Sickness means sickness or disease of the Insured Person which causes loss while the<br />
Insured Person is covered under this policy, subject to the policy Pre-existing Condition<br />
provisions. All related conditions <strong>and</strong> recurrent symptoms of the same or a similar condition<br />
will be considered one sickness. Covered Medical Expenses incurred as a result of an Injury<br />
that occurred prior to this policy's Effective Date will be considered a sickness under this policy.<br />
Totally Diabled means a condition of a Named Insured which, because of Sickness or<br />
Injury, renders the Insured unable to actively attend class.<br />
Usual <strong>and</strong> Customary Charges means a reasonable charge which is: 1) usual <strong>and</strong><br />
customary when compared with the charges made for similar services <strong>and</strong> supplies; <strong>and</strong> 2)<br />
made to persons having similar medical conditions in the locality where service is rendered.<br />
No payment will be made under this policy for any expenses incurred which in the judgment<br />
of the Company are in excess of Usual <strong>and</strong> Customary Charges.<br />
Exclusions And Limitations<br />
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from;<br />
or b) treatment, services or supplies for, at, or related to:<br />
1. Acupuncture, allergy testing;<br />
2. Biofeedback;<br />
3. Circumcision;<br />
4. Congenital conditions, except as specifically provided for Newborn or adopted Infants;<br />
5. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which<br />
benefits are otherwise payable under this policy or for newborn or adopted children;<br />
6. Dental treatment, except as specifically provided in the Policy;<br />
7. Elective Surgery or Elective Treatment;<br />
8. Elective abortion;<br />
9. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or<br />
contact lenses; except when due to a disease process;<br />
10. Foot care including: care of corns, bunions (except capsular or bone surgery) <strong>and</strong><br />
calluses;<br />
11. Hearing examinations or hearing aids or other treatment for hearing defects <strong>and</strong><br />
problems. "Hearing defects" means any physical defect of the ear which does or can<br />
impair normal hearing, apart from the disease process;<br />
<strong>12</strong>. Hirsutism; alopecia;<br />
14
13. Immunizations, except as specifically provided in the policy; preventive medicines or<br />
vaccines, except where required for treatment of a covered Injury, except as<br />
specifically provided in the policy;<br />
14. Injury or Sickness for which benefits are paid or payable under any Workers'<br />
Compensation or Occupational Disease Law or Act, or similar legislation;<br />
<strong>15</strong>. Lipectomy;<br />
16. Organ transplants;<br />
17. Participation in a riot, civil disorder or a felony, except when Injury occurs when the<br />
Insured Person has an elevated blood alcohol content or when under the influence of<br />
intoxication liquor or any drug or both. Participation means to voluntarily take a part or<br />
share with others assembled together in some activity. Riot means a violent public<br />
disturbance of the peace by a number of persons assembled together;<br />
18. Prescription Drugs, services or supplies as follows, except as specifically provided in<br />
the policy:<br />
a) Therapeutic devices or appliances, including: hypodermic needles <strong>and</strong> syringes,<br />
except for hypodermic needles or syringes prescribed by a Physician for the<br />
purpose of administering medications for medical conditions, provided such<br />
medications are covered under the policy, support garments <strong>and</strong> other non-medical<br />
substances;<br />
b) Immunization agents, biological sera, blood or blood products administered on an<br />
outpatient basis;<br />
c) Drugs labeled, "Caution-limited by federal law to investigational use" or<br />
experimental drugs except for drugs for the treatment of cancer that have not been<br />
approved by the Federal Food <strong>and</strong> Drug Administration, provided the drug is<br />
recognized for treatment of the specific type of cancer for which the drug has been<br />
prescribed in one of the following established reference compendia: (1) The U.S.<br />
Pharmacopeia Drug Information Guide for the Health Care Professional (USP DI);<br />
(2) The American Medical Association's Drug Evaluations (AMA DE); or (3) The<br />
American Society of Hospital Pharmacist's American Hospital Formulary Service<br />
Drug Information (AHFS-DI);<br />
d) Products used for cosmetic purposes;<br />
e) Drugs used to treat or cure baldness; anabolic steroids used for body building;<br />
f) Anorectics- drugs used for the purpose of weight control;<br />
g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid,<br />
Profasi, Metrodin, Serophene, or Viagra; except as specifically provided in the<br />
Benefits for Infertility Treatment;<br />
h) Growth hormones; or<br />
i) Refills in excess of the number specified or dispensed <strong>after</strong> one (1) year of date of<br />
the prescription;<br />
19. Reproductive/Infertility services including but not limited to: family planning; fertility<br />
tests; infertility (male or female), including any services or supplies rendered for the<br />
purpose or with the intent of inducing conception; except as specifically provided in<br />
the Benefits for Infertility Treatment;<br />
20. Routine Newborn Infant Care, well-baby nursery <strong>and</strong> related Physician charges in<br />
excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; except as<br />
specifically provided in the policy;<br />
21. Routine physical examinations <strong>and</strong> routine testing; preventive testing or treatment;<br />
screening exams or testing in the absence of Injury or Sickness; except as specifically<br />
provided in the policy;<br />
<strong>15</strong>
22. Skeletal irregularities of one or both jaws, including orthognathia <strong>and</strong> m<strong>and</strong>ibular<br />
retrognathia, except as specifically provided in the Benefits for Treatment of Craniofacial<br />
Disorders;<br />
23. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee<br />
jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly<br />
scheduled flight of a commercial airline;<br />
24. Sleep disorders;<br />
25. Unless specifically covered under Benefits for Mental or Nervous Conditions, Injury<br />
resulting from suicide or attempted suicide while sane or insane (including intentional<br />
drug overdose); or intentionally self-inflicted Injury;<br />
26. Supplies, except as specifically provided in the policy;<br />
27. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic<br />
devices, or gynecomastia; except as specifically provided in the Benefits for<br />
Reconstructive Breast Surgery <strong>and</strong> Benefits for Treatment of Tumors <strong>and</strong> Leukemia;<br />
28. Treatment in a Government hospital for which the Insured is not charged, unless there is<br />
a legal obligation for the Insured Person to pay for such treatment;<br />
29. War or any act of war, declared or undeclared; or while in the armed forces of any country<br />
(a pro-rata premium will be refunded upon request for such period not covered); <strong>and</strong><br />
30. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery<br />
for removal of excess skin or fat, <strong>and</strong> treatment of eating disorders such as bulimia <strong>and</strong><br />
anorexia, except as specifically provided in the policy. Exception: benefits will be provided<br />
or the treatment of dehydration <strong>and</strong> electrolyte imbalance associated with eating<br />
disorders.<br />
General Provisions<br />
The Insurer will furnish the Insured the necessary forms for filing proof of loss. Claim forms<br />
may be obtained at the Company, P.O. Box 809025, Dallas, Texas 75380-9025.<br />
If the person making claim does not receive the necessary claim forms before the expiration<br />
of <strong>15</strong> days <strong>after</strong> first requesting such forms, the Insured Person shall be deemed to have<br />
complied with the requirements as to the proof of loss upon submitting to the Insured within<br />
90 days written proof covering the occurrence, character <strong>and</strong> extent of the loss for which<br />
claim is made.<br />
Written proof of loss must be submitted to the Company at P.O. Box 809025, Dallas, Texas<br />
75380-9025 within 90 days <strong>after</strong> expense is incurred, or as soon there<strong>after</strong> as reasonably<br />
possible.<br />
The Company, at its own expense, shall have the right <strong>and</strong> opportunity to examine the<br />
Insured as often as it may reasonably require <strong>and</strong> also may make an autopsy in case of<br />
death if not prohibited by law. Failure of an insured to present himself or herself for<br />
examination by a Physician when requested shall authorize the Company to: 1) withhold<br />
any payment of Covered Medical Expenses until such examination is performed <strong>and</strong><br />
Physician's report received; <strong>and</strong> 2) deduct from any amounts otherwise payable hereunder<br />
any amount for which the Company has been obligated to pay a Physician retained by the<br />
Company to make an examination for which the insured failed to appear. Said deduction<br />
shall be made with the same force <strong>and</strong> effect as a Deductible herein defined.<br />
All benefits payable under the Policy will be paid upon receipt of due written proof of loss.<br />
All benefits are payable to the Insured or his designated beneficiary or beneficiaries or to<br />
his estate, except that if the person insured be a minor, such benefits may be made payable<br />
to his parents, guardian or other person actually supporting him. Subject to any written<br />
direction of the Insured, all or a portion of any benefits payable under the Policy may be paid<br />
directly to the Hospital, Physician or person rendering the service or treatment.<br />
No action shall be brought under the Policy prior to the expiration of 60 days <strong>after</strong> filing<br />
written proof of loss <strong>and</strong> no action may be brought <strong>after</strong> 3 years from the date within which<br />
proof of loss is required by the Policy.<br />
16
Scholastic Emergency Services:<br />
Global Emergency Medical Assistance<br />
If you are a student insured with this insurance plan, you are eligible for Scholastic<br />
Emergency Services (SES). The requirements to receive these services are as follows:<br />
International Students: You are eligible to receive SES worldwide, except in your home<br />
country.<br />
Domestic Students: You are eligible for SES when 100 miles or more away from your<br />
campus address <strong>and</strong> 100 miles or more away from your permanent home address or while<br />
participating in a Study Abroad program.<br />
SES includes Emergency Medical Evacuation <strong>and</strong> Return of Mortal Remains that meet the<br />
US State Department requirements. The Emergency Medical Evacuation services are not<br />
meant to be used in lieu of or replace local emergency services such as an ambulance<br />
requested through emergency 911 telephone assistance. All SES services must be<br />
arranged <strong>and</strong> provided by SES, Inc.; any services not arranged by SES, Inc. will not be<br />
considered for payment.<br />
Key Services include:<br />
* Medical Consultation, Evaluation <strong>and</strong> Referrals * Prescription Assistance<br />
* Foreign Hospital Admission Guarantee * Critical Care Monitoring<br />
* Emergency Medical Evacuation * Return of Mortal Remains<br />
* Medically Supervised Repatriation * Transportation to Join Patient<br />
* Emergency Counseling Services * Interpreter <strong>and</strong> Legal Referrals<br />
* Lost Luggage or Document Assistance<br />
* Care for Minor Children Left Unattended Due to a Medical Incident<br />
Please visit your school's insurance coverage page at www.uhcsr.com for the SES Global<br />
Emergency Assistance Services brochure which includes service descriptions <strong>and</strong> program<br />
exclusions <strong>and</strong> limitations.<br />
To access services please call:<br />
(877) 488-9833 Toll-free within the United States<br />
(609) 452-8570 Collect outside the United States<br />
Services are also accessible via e-mail at medservices@assistamerica.com.<br />
When calling the SES Operations Center, please be prepared to provide:<br />
1. Caller's name, telephone <strong>and</strong> (if possible) fax number, <strong>and</strong> relationship to the patient;<br />
2. Patient's name, age, sex, <strong>and</strong> Reference Number;<br />
3. Description of the patient's condition;<br />
4. Name, location, <strong>and</strong> telephone number of hospital, if applicable;<br />
5. Name <strong>and</strong> telephone number of the attending physician; <strong>and</strong><br />
6. Information of where the physician can be immediately reached.<br />
SES is not travel or medical insurance but a service provider for emergency medical<br />
assistance services. All medical costs incurred should be submitted to your health plan <strong>and</strong><br />
are subject to the policy limits of your health coverage. All assistance services must be<br />
arranged <strong>and</strong> provided by SES, Inc. Claims for reimbursement of services not provided by<br />
SES will not be accepted. Please refer to your SES brochure or Program Guide at<br />
www.uhcsr.com for additional information, including limitations <strong>and</strong> exclusions pertaining to<br />
the SES program.<br />
17
Claim Procedure<br />
In the event of Injury or Sickness, students should:<br />
1) Report at once to the Student Health Service or Infirmary for treatment, or when not<br />
in school, to the nearest Physician or Hospital.<br />
2) Secure a Company claim form from the Student Health Service or from the address<br />
below, fill out the form completely, attach all medical <strong>and</strong> hospital bills <strong>and</strong> mail to<br />
the address below.<br />
3) File claim within 30 days of Injury or first treatment for a Sickness. Bills must be<br />
received by the Company within 90 days of service. Bills submitted <strong>after</strong> one year<br />
will not be considered for payment except in the absence of legal capacity.<br />
The Plan is Underwritten by:<br />
UnitedHealthcare Insurance Company<br />
Submit all Claims or Inquiries to:<br />
UnitedHealthcare StudentResources<br />
P.O. Box 809025<br />
Dallas, Texas 75380-9025<br />
1-888-455-9402<br />
Sales/Marketing Service:<br />
UnitedHealthcare StudentResources<br />
805 Executive Center Drive West, Suite 220<br />
St. Petersburg, FL 33702<br />
Please keep this Certificate as a general summary of the insurance. The Master Policy on<br />
file at the school contains all of the provisions, limitations, exclusions <strong>and</strong> qualifications of<br />
your insurance benefits, some of which may not be included in this Certificate.<br />
The Master Policy is the contract <strong>and</strong> will govern <strong>and</strong> control payment of benefits.<br />
This Certificate is based on Policy<br />
20<strong>12</strong>-1806-1<br />
v2
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suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
ACKNOWLEDGEMENT OF SUFFIELD ACADEMY MEDICAL PHILOSOPHY<br />
NAME OF STUDENT<br />
First Name Last Name Middle Name<br />
All <strong>Suffield</strong> students, both returning <strong>and</strong> new, must have an annual physical. A physical completed <strong>after</strong> March 1 of this year is acceptable for the upcoming<br />
school year. The completed form must be returned by the physician to the Health Center by July <strong>15</strong>. If, for insurance constraints, you are unable to have a<br />
physical completed <strong>and</strong> returned by July <strong>15</strong>, please notify the Health Center with the date of the physical. Should this date fall <strong>after</strong> the start of school, a note<br />
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 <strong>and</strong><br />
athletic activities until the time of the physical. No student will be allowed to participate in the above without a physical or note.<br />
Prescriptions that are self-administered must be accompanied by written directions as to strength, dose, <strong>and</strong> duration by the student’s physician. Prescriptions<br />
for controlled substance drugs must be kept at the Health Center. All prescription medication kept on campus must be checked in through the<br />
Health Center. Medications that are to be kept in the dormitory will be noted in the medical record, <strong>and</strong> the Health Center will affix a label to the bottle<br />
identifying that this is safe to keep in the dorm <strong>and</strong> is documented. Medication not checked-in is considered contrab<strong>and</strong>, <strong>and</strong> the matter will be transferred to the<br />
Dean of Students’ Office. A few medications (controlled <strong>and</strong> many psychotropics) are required to be kept in the Health Center <strong>and</strong> dispensed by the Health Center<br />
staff. All medications must be brought to the Health Center within 24 hours upon arrival or return to school.<br />
Any required immunizations that are not complete may be administered at the Health Center.<br />
Please check electronic signature approval box (or sign) below to ack<strong>now</strong>ledge you underst<strong>and</strong> <strong>Suffield</strong>’s medical philosophy <strong>and</strong> that you have completed all the<br />
medical forms to the best of your k<strong>now</strong>ledge.<br />
Parent or Guardian Name (please print <strong>and</strong> sign here if you intend to use a printed copy of this form)<br />
Date<br />
By checking this box <strong>and</strong> entering the student ID number above, you are signing this document electronically.<br />
[<br />
FORM: MEDICAL / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
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suffield academy<br />
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20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
PHYSICAL EXAMINATION RECORD FOR NEW STUDENTS<br />
Please be thorough. Omission of k<strong>now</strong>n health problems can jeopardize a student’s health care <strong>and</strong> well-being. A physical examination must be filed each year<br />
before a student may participate in any part of the school program. Physical must be done within one year.<br />
NAME OF STUDENT<br />
First Name last Name middle Name<br />
Blood pressure Pulse Asthma (preventative & emergency treatment)<br />
Height<br />
Weight<br />
Urinalysis<br />
sugar<br />
albumin<br />
micro<br />
Hemoglobin or hematocrit<br />
Prior medical/psychological conditions:<br />
Previous musculoskeletal injuries:<br />
Current medical/psychological conditions:<br />
Psychotherapy or counseling history:<br />
inches<br />
pounds<br />
Allergies (please list)<br />
Review of Systems Describe fully. Use additional sheet if needed.<br />
WNL<br />
Head, ears, nose, throat<br />
Hearing<br />
Respiratory<br />
Cardiovascular<br />
Gastrointestinal<br />
Hernia<br />
Eyes<br />
Genitourinary<br />
Musculoskeletal<br />
Metabolic/endocrine<br />
Neuropsychiatric<br />
Skin<br />
Any other conditions<br />
ABNL<br />
Medications to be continued at school<br />
(please list dose <strong>and</strong> schedule for each medication)<br />
My examination finds the student named above to be in good health, free from contagion, <strong>and</strong> physically <strong>and</strong> emotionally qualified for a full program of study <strong>and</strong> sports.<br />
Yes No If no, please explain:<br />
Print or type name <strong>and</strong> address of examining physician<br />
Name<br />
Phone Number<br />
Street City State Country Zip Code<br />
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FORM: EXAMNEW / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
Physician’s Signature (required)<br />
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Date
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suffield academy<br />
<strong>Suffield</strong>, Connecticut / 860.386.4400<br />
IMPORTANT INFORMATION ABOUT INFLUENZA AND INFLUENZA VACCINE<br />
What is Influenza (“Flu”)?<br />
Influenza (or “flu”) is a viral infection of the nose, throat, bronchial tubes <strong>and</strong> lungs that can make someone of any age ill. Usually the flu occurs in the United<br />
States from about November to April. If you get the flu, you usually have fever, chills, cough <strong>and</strong> soreness <strong>and</strong> aching in your back, arms <strong>and</strong> legs. Although<br />
most people are ill for only a few days, some persons have a much more serious illness <strong>and</strong> may need to go to the hospital. On average, thous<strong>and</strong>s of people<br />
die each year in the United States from the flu or related complications.<br />
Who Should Get Influenza Vaccine?<br />
Because influenza is usually not life threatening in healthy individuals <strong>and</strong> most people recover fully, health officials emphasize the use of vaccine for<br />
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<br />
vaccine include:<br />
• children <strong>and</strong> adults with severe asthma, heart disease, diabetes, cystic fibrosis, kidney disease or anemia which has required<br />
regular visits to the doctor or hospitalization<br />
• children <strong>and</strong> adults who have a type of cancer or immunological disorder that lowers the body’s normal resistance to infections<br />
• children <strong>and</strong> teenagers on long-term treatment with aspirin who, if they catch the flu, may be at risk of getting Reye’s syndrome<br />
(a childhood disease that causes coma, liver damage <strong>and</strong> death)<br />
• residents of institutions housing patients of any age who have serious long-term health problems<br />
In addition, any person wishing to reduce their chances of getting the flu may choose to receive a flu shot, including:<br />
• students or other persons in schools <strong>and</strong> colleges, if a flu outbreak would cause major disruptions of school activities<br />
• persons traveling to the tropics at any time of the year or to countries to the south of the equator during April–September<br />
Influenza Vaccine<br />
Only a single flu shot is needed each season for persons 9 years of age <strong>and</strong> older, but children 8 years of age or younger may need a second shot <strong>after</strong> a month.<br />
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<br />
effects. Split-virus vaccines can also be used by adults.<br />
Possible Side Effects from the Vaccine<br />
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<br />
soreness for a day or two at the injection site <strong>and</strong> occasionally may also cause a fever or achiness for one or two days. Unlike the 1976 swine flu vaccine, recent<br />
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<br />
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<br />
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<br />
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<br />
the flu shot.<br />
People who Should Check with a Doctor Before Taking Influenza Vaccine<br />
• Persons with an allergy to eggs that causes a dangerous reaction if they eat eggs <strong>and</strong> those who have had a serious reaction to previous<br />
influenza vaccination should consult a physician before receiving the vaccine.<br />
• Anyone who has ever been paralyzed with Guillain-Barr syndrome should seek advice from their doctor about special risks that might<br />
exist in their cases.<br />
• Women who are or might be pregnant should consult with their doctor.<br />
• Persons who are ill <strong>and</strong> have a fever should ask their doctor whether or not they should delay vaccination until the fever <strong>and</strong> other<br />
temporary symptoms have gone.<br />
Questions<br />
If you have any questions about influenza or influenza vaccination, please call us at the Health Center at 860-386-4503 or call your<br />
child’s doctor before signing this form.<br />
[<br />
FORM: FLUVACCINE / DUE: 07.<strong>15</strong>.<strong>12</strong>
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suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
Permission to Administer Influenza Vaccine<br />
Please sign <strong>and</strong> return this form, indicating your instructions. The cost of the vaccine is $25<br />
I have read the information sheet <strong>and</strong> I hereby authorize the Health Center staff to administer the influenza vaccine to:<br />
NAME OF STUDENT<br />
First Name Last Name Middle Name<br />
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.<br />
Parent or Guardian Name (please print <strong>and</strong> sign here if you intend to use a printed copy of this form)<br />
date<br />
By checking this box <strong>and</strong> entering the student ID number above, you are signing this document electronically.<br />
[<br />
FORM: FLUVACCINE / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
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[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
IMMUNIZATION HISTORY FOR NEW STUDENTS<br />
CONNECTICUT STATE LAW requires the following<br />
DTaP/Td/Tdap at least 4 doses. Last dose must be given on/ <strong>after</strong> the 4th birthday. Students who start series at age 7 or older only need a total of 3 doses.<br />
Polio at least 3 doses. The last dose must be given on or <strong>after</strong> the 4th birthday.<br />
MMR 2 doses separated by at least 28 days, 1st dose on or <strong>after</strong> the 1st birthday.<br />
Hepatitis B 3 doses, last dose on/<strong>after</strong> 24 weeks of age.<br />
A Varicella (chickenpox) 1 dose on or <strong>after</strong> the 1st birthday or verification of disease.<br />
NAME OF STUDENT<br />
First Name Last Name middle Name<br />
Immunization History (please list all dates; boxes with an * must include a month/day/year date)<br />
DTaP/Td/Tdap<br />
TOPV/IPV (three doses; one dose <strong>after</strong> age 4)<br />
M.M.R<br />
or<br />
1. German Measles (Rubella)<br />
2. Measles<br />
3. Mumps<br />
Hepatitis B<br />
HIB<br />
1 2 3 4 5 6<br />
* * * *<br />
* * *<br />
* *<br />
*<br />
*<br />
*<br />
*<br />
*<br />
* *<br />
Varicella (chickenpox)<br />
(immunization or date of disease)<br />
Meningitis (recommended)<br />
Hepatitis A<br />
Gardisil (HPV)<br />
*<br />
*<br />
Tuberculin skin test (required for new students within the past year)<br />
Date Type results negative positive (if result is positive; chest x-ray required)<br />
Physician’s Signature (required)<br />
Date<br />
[<br />
FORM: IMMUNIZATION / DUE: 07.<strong>15</strong>.<strong>12</strong>
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suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
PERMISSION FOR MEDICAL OR SURGICAL TREATMENT<br />
Treatment Waiver: This form must be signed by the student’s parent or legal guardian so that appropriate diagnosis <strong>and</strong> treatment may be promptly administered <strong>and</strong> so that no unnecessary<br />
delays will occur in case of a medical or surgical emergency. In the event of an emergency, every attempt will be made to contact <strong>and</strong> fully inform the parents or legal guardian. I hereby authorize the<br />
physician (M.D.) of <strong>Suffield</strong> <strong>Academy</strong>, <strong>Suffield</strong>, Connecticut, to procure <strong>and</strong> administer any care, medical or surgical, <strong>and</strong> any hospital care deemed necessary to restore health to my son or daughter.<br />
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<br />
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<br />
medications prescribed by the school physician or consulting physician. I further authorize that medical information be released to faculty <strong>and</strong> advisors on a need to k<strong>now</strong> basis.<br />
NAME OF STUDENT<br />
First Name Last Name middle Name<br />
Student’s Social Security Number<br />
List Any K<strong>now</strong>n Allergies<br />
Parent or Guardian Name (please print <strong>and</strong> sign here if you intend to use a printed copy of this form)<br />
Date<br />
By checking this box <strong>and</strong> entering the student ID number above, you are signing this document electronically.<br />
PARENT or guardian CONTACT INFORMATION<br />
Name<br />
relationship to Student<br />
Street City State Country Zip Code<br />
Home Phone<br />
Cell Phone<br />
Business Phone<br />
Email<br />
IN CASE the PARENT or guardian listed above cannot be reached, please contact<br />
Name<br />
relationship to Student<br />
Street City State Country Zip Code<br />
Home Phone<br />
Cell Phone<br />
Business Phone<br />
Email<br />
MEDICAL INSURANCE INFORMATION<br />
Is a referral needed PCP Name Phone Fax<br />
Name of Insurance<br />
insurance Company’s Phone Number<br />
Address to mail claim form<br />
Name of Subscriber<br />
Subscriber’s Date of Birth<br />
Subscriber’s Place of Employment<br />
Insurance Identification Number<br />
Subscriber’s Social Security number<br />
[<br />
PLEASE PROVIDE AN ENLARGED COPY OF THE FRONT AND BACK OF ALL INSURANCE CARDS<br />
FORM: TREATMENT / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
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[<br />
[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
AUTHORIZATION FOR THE ADMINISTRATION OF PRESCRIPTION MEDICINE<br />
BY SCHOOL PERSONNEL<br />
Any medication prescribed for a student must be reported to the Health Center. This form must be completed for all controlled substances, mood<br />
altering medications, <strong>and</strong> any other medication to be dispensed by school personnel. Connecticut State statute requires a physician’s or dentist’s written order<br />
<strong>and</strong> the parent’s/guardian’s authorization for a nurse to administer prescription medicine.<br />
Medications must be in pharmacy-prepared blister-pack containers <strong>and</strong> labeled with the student’s name, name of the drug, strength, dose, frequency, physician’s<br />
or dentist’s name, <strong>and</strong> date of the original prescription. The physician’s name <strong>and</strong> order must be the same on the authorization form <strong>and</strong> prescription bottle.<br />
All prescriptions may be included on this form. Photocopies of this form are acceptable.<br />
PHYSICIAN’S ORDER<br />
NAME OF STUDENT<br />
First Name Last Name Middle Name<br />
Diagnosis:<br />
I have evaluated <strong>and</strong> examined the student on (date)<br />
<strong>and</strong> plan to reassess the medication <strong>and</strong> treatment plan on (date)<br />
Drug: (name, dose, frequency <strong>and</strong> method of administration)<br />
Medication shall be administered from: (date)<br />
to: (date)<br />
Relevant side effects to be observed, if any:<br />
If there are side effects, give plan for management:<br />
Is this a controlled drug? Yes No If yes, DEA #<br />
type name <strong>and</strong> address of examining physician<br />
Name<br />
Phone Number<br />
Street City State Country Zip Code<br />
Physician’s Signature (required)<br />
Date<br />
[<br />
FORM: PRESCRIPTION / DUE: 07.<strong>15</strong>.<strong>12</strong>
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suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
<strong>Suffield</strong> <strong>Academy</strong> Concussion Testing<br />
Every student at <strong>Suffield</strong> <strong>Academy</strong> is required to participate in our ImPact Concussion testing program. The ImPACT test provides computerized neurocognitive<br />
assessment tools <strong>and</strong> services that are used by medical doctors, psychologists, athletic trainers, <strong>and</strong> other licensed healthcare professionals to assist them in<br />
determining an athlete’s ability to return to play <strong>after</strong> suffering a concussion.<br />
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 <strong>and</strong> exhibit concussive symptoms,<br />
they take the test again <strong>and</strong> their scores are compared to their baseline. Along with these scores <strong>and</strong> their current symptoms an evaluation <strong>and</strong> plan are<br />
made to help the student rest <strong>and</strong> heal accordingly. When the student is symptom free <strong>and</strong> has good ImPact scores compared to baseline, they begin our<br />
supervised return to play protocol. The return to play protocol consists of biking, jogging, non-contact, <strong>and</strong> contact sports, eventually clearing them to return<br />
to play their sport.<br />
We require that new students take their baseline tests at home before they come to school. Students will not be allowed to begin their<br />
athletic season until they have taken a baseline test.<br />
• Tests should be taken in a quiet room, away from distractions, with the computer plugged in to a power source.<br />
• Tests are taken using the Safari internet browser<br />
• An External Mouse must be used<br />
Impact Test Instructions<br />
1. Open broswer.<br />
2. Uncheck “Block Pop-Up Windows” in your browser.<br />
3. In the browser type in “https://www.impacttestonline.com/colleges” <strong>and</strong> hit the return button.<br />
4. In the pull down menu for “Please Select Your Organization” select Connecticut then hit the “Launch Baseline Test” button.<br />
5. When prompted, enter the following code: 584<strong>15</strong>F7283. After entering the code hit the “Launch Baseline Test” button.<br />
6. Read all instructions carefully.<br />
7. You will be asked what country you are from. If your country is not listed, pick the closest country geographically.<br />
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.<br />
9. Read all the directions very carefully <strong>and</strong> take your time.<br />
10. The test will take approximately 30-35 minutes.<br />
The school will be notified upon your completion.<br />
[FORM IMPACTTEST DUE: 07.<strong>15</strong>.<strong>12</strong>
[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
PRIVATE MUSIC LESSON PROGRAM<br />
The Music Department of <strong>Suffield</strong> <strong>Academy</strong> offers private lessons at all levels for voice as well as instruments. Lessons are offered once each week <strong>and</strong> students<br />
are expected to practice regularly. A year-round commitment is important for substantial growth.<br />
In order to secure contracts with professional teachers, it is necessary for the <strong>Academy</strong> to commit financially to them in advance of the<br />
start of lessons. The cost of a full year of lessons is $925 (24 lessons), payable in advance to <strong>Suffield</strong> <strong>Academy</strong>.<br />
Students interested in scheduling private lessons should read the list of Student/Teacher Commitments below <strong>and</strong> fill in <strong>and</strong> sign the statement at the bottom,<br />
returning it with a check by September 10.<br />
STUDENT/TEACHER COMMITMENTS<br />
1. In the case of an unexcused absence from a lesson, the teacher will be paid <strong>and</strong> the lesson will not be rescheduled. In the case of two unexcused<br />
absences, the student’s parents <strong>and</strong> advisor will be notified <strong>and</strong> the possibility of discontinuing lessons discussed. If the number of<br />
these absences continues to four, parents <strong>and</strong> advisor will be notified again with the assumption that the student is not interested in<br />
lessons. The teacher will be paid for the lessons missed, <strong>and</strong> any balance of payment returned.<br />
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<br />
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<br />
school, the teacher <strong>and</strong> the Music Department office must be notified directly <strong>and</strong> immediately.<br />
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.<br />
3. If a student cannot make a lesson for some other personal or school-related reason, <strong>and</strong> notifies the teacher at least 24 hours in advance, every effort will<br />
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.<br />
Please arrange for private music lessons at <strong>Suffield</strong> <strong>Academy</strong> for:<br />
Student Name<br />
Instrument<br />
Please send payment for $925.00 (payable in U.S. dollars to <strong>Suffield</strong> <strong>Academy</strong>) along with a copy of this form to <strong>Suffield</strong> <strong>Academy</strong>, Attn: Tom Gotwals<br />
185 North Main Street, <strong>Suffield</strong>, CT 06078.<br />
I underst<strong>and</strong> <strong>and</strong> agree with the policies regarding private lessons.<br />
Parent or Guardian Name (please print <strong>and</strong> sign here if you intend to use a printed copy of this form)<br />
Date<br />
By checking this box <strong>and</strong> entering the student ID number above, you are signing this document electronically.<br />
[<br />
FORM: MUSIC / DUE: 07.<strong>15</strong>.<strong>12</strong><br />
[
[<br />
[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
Photo & Press Release Form<br />
I. Permission for Use of Name <strong>and</strong> Photographs<br />
The Marketing <strong>and</strong> Communications Office at <strong>Suffield</strong> <strong>Academy</strong> is responsible for the overall marketing of the school, which includes press about <strong>Suffield</strong><br />
students. Toward that end, names <strong>and</strong> photographs of <strong>Suffield</strong> students are used on the school’s website, in the <strong>Academy</strong>’s alumni magazine, other school<br />
publications as needed, in regional <strong>and</strong> national magazines <strong>and</strong> newspapers, <strong>and</strong> in other forms of media, such as social media websites. In addition, the school<br />
creates certain administrative publications that include student names <strong>and</strong> addresses <strong>and</strong> parents’ names <strong>and</strong> email addresses.<br />
As parent or legal guardian of ____________________________________________________ I give permission to <strong>Suffield</strong> <strong>Academy</strong> to use the names,<br />
Student Name<br />
information <strong>and</strong> photographs of the aforementioned student for school advertising, marketing initiatives, administrative publications <strong>and</strong> other similar purposes<br />
that are intended to promote <strong>Suffield</strong> <strong>Academy</strong>.<br />
II. Press Release Information<br />
Please list the complete name <strong>and</strong> address of all of your local newspapers so we may share the good news about your child’s honor roll achievements, athletic<br />
awards, <strong>and</strong> Commencement.<br />
NAME OF STUDENT<br />
First Name last Name middle Name Year of Graduation<br />
Newspaper Name<br />
City<br />
State/Country<br />
Newspaper Name<br />
City<br />
State/Country<br />
Newspaper Name<br />
City<br />
State/Country<br />
Parent or Guardian Name (please print <strong>and</strong> sign here if you intend to use a printed copy of this form)<br />
date<br />
Check here if you do not want your child’s name released to local papers.<br />
By checking this box you indicate that you accept <strong>and</strong> ack<strong>now</strong>ledge permissions to use name, information,<br />
<strong>and</strong> photographs of your child in <strong>Suffield</strong> publications, advertisements, websites, <strong>and</strong> newspapers.<br />
[<br />
FORM: release DUE: 07.<strong>15</strong>.<strong>12</strong>
[<br />
[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
Back to School Shipping In-Room Delivery (<strong>Order</strong> Estimate)<br />
NAME OF STUDENT<br />
First Name Last Name middle Name school<br />
Street City State Zip Code<br />
Country<br />
Home Phone<br />
Email<br />
Items to Ship<br />
Box Weight (lbs.) Box Dimensions (L x W x H) Declared Value Insurance<br />
1.<br />
2.<br />
3.<br />
4.<br />
5.<br />
Important Reminder: Please pack your boxes to meet packaging guidelines for UPS declared value coverage!<br />
• A minimum of 2” of cushioning around all sides of the box.<br />
• Box should be able to withst<strong>and</strong> a drop from 3 feet high<br />
• No shifting or movement of items within the box.<br />
• Fragile items should be bubble-wrapped <strong>and</strong> double boxed.<br />
Please plan ahead. We must receive your boxes by 8/31/20<strong>12</strong> in order to provide In-Room delivery service.<br />
Please complete information above <strong>and</strong> fax or email to The UPS Store. We will respond with the your pricing quote based upon weights <strong>and</strong> dimensions provided.<br />
Phone: 860-871-7499 Fax: 860-871-8186 Email: store2195@theupsstore.com<br />
Price<br />
Signature<br />
Card #<br />
Exp<br />
Card Type<br />
Billing Zip<br />
Security Code<br />
[<br />
FORM: SHIPPING / DUE: 07.<strong>15</strong>.<strong>12</strong>
[<br />
suffield academy<br />
<strong>Suffield</strong>, Connecticut / 860.386.4400<br />
E&R LAUNDRY SERVICE<br />
Dear <strong>Suffield</strong> <strong>Academy</strong> Parents:<br />
In the 20<strong>12</strong>-13 academic year, <strong>Suffield</strong> <strong>Academy</strong> <strong>and</strong> E&R—The Campus Laundry will once again partner to provide laundry services to all interested students.<br />
Anyone who has been in academia for a number of years comes to underst<strong>and</strong> certain realities about student life; in particular that cleaning rooms <strong>and</strong><br />
laundering clothes <strong>and</strong> bed sheets have become low priorities for many students, given their increasingly busy schedules.<br />
To help address this issue, E&R offers two especially efficient <strong>and</strong> practical programs—Look Sharp <strong>and</strong> Just the Basics. E&R has provided professional<br />
laundry services to over 100 preparatory schools, colleges <strong>and</strong> universities throughout the Northeast for over 50 years, <strong>and</strong> has designed its plans to allow<br />
students to make the most of their free time. <strong>Suffield</strong> <strong>Academy</strong> strongly recommends that you select one of these plans, which are currently available at<br />
discounted rates.<br />
To help you make the best selection for your student, the chart below compares the benefits of each of E&R’s service options:<br />
Features<br />
Wash/dry/fold laundry; neatly folded <strong>and</strong> right-side-out.<br />
Includes personal bed <strong>and</strong> bath linens (sheets, pillowcases, towels, face cloths, etc.) in addition to your clothing.<br />
Launderable, button-down dress shirts <strong>and</strong> blouses are pressed <strong>and</strong> returned on hangers.<br />
Gentle care washing, drying <strong>and</strong> pressing. *<br />
Skirts, dress pants <strong>and</strong> dress shorts, including khakis, returned pressed <strong>and</strong> on hangers. *<br />
Polo/Sport shirts returned pressed <strong>and</strong> on hangers. *<br />
Sweaters returned pressed <strong>and</strong> on hangers. *<br />
Professional dry cleaning <strong>and</strong> pressing. *<br />
Comforter <strong>and</strong> Blanket Cleaning Plan FREE: A $70 Value *<br />
*Service available for an additional fee; see the attached brochure for more details.<br />
Look<br />
Sharp<br />
◊<br />
◊<br />
◊<br />
◊<br />
◊<br />
◊<br />
◊<br />
◊<br />
◊<br />
Just the<br />
Basics<br />
◊<br />
◊<br />
◊<br />
*<br />
*<br />
*<br />
The Look Sharp <strong>and</strong> Just the Basics plans from E&R not only maximize your student’s available free time <strong>and</strong> promote a clean <strong>and</strong> healthy dorm room, they<br />
also help to reduce the school’s carbon footprint. Although the campus washers <strong>and</strong> dryers are relatively efficient, they cannot compare with the equipment at<br />
E&R’s central laundering facility in terms of gas, electricity, <strong>and</strong> water usage.<br />
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<br />
registration information back to them. Please see the enclosed registration form <strong>and</strong> promotional materials for details on how to order. Registration for any E&R<br />
service should be completed no later than August <strong>15</strong>th, 20<strong>12</strong> to receive E&R’s discounted rates.<br />
Over the years, E&R—The Campus Laundry has demonstrated a proven track record of providing reliable, professional <strong>and</strong> top quality<br />
service. We hope that you will consider subscribing to one of their service plans.<br />
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<br />
your record of E&R’s policies <strong>and</strong> procedures.<br />
[FORM LAUNDRY DUE: 08.<strong>15</strong>.<strong>12</strong>
Since 1921 Since 1921<br />
6078 • (860) 668-73<strong>15</strong> • Fax (860) 668-2966<br />
<strong>Order</strong><br />
Now<br />
Password<br />
CS70<br />
Increase your<br />
Academic Advantage<br />
Free Up<br />
With<br />
Time<br />
Our<br />
with<br />
“Look<br />
One<br />
Sharp”<br />
of Our Great<br />
Plan,<br />
Plans!<br />
You Also Get:<br />
“I had E&R in the 70s<br />
<strong>and</strong> <strong>now</strong> my son is<br />
using them.”<br />
– Facebook Dad quote<br />
86 % Water<br />
Savings<br />
“Peace of mind for a<br />
freshman <strong>and</strong> her<br />
parents! Thank you.”<br />
– Facebook Mom quote<br />
“BE NVIRONMENTALLY ESPONSIBLE”<br />
Register online at www.TheCampusLaundry.com using password CS7Ø<br />
Our “LOOK SHARP” Plan: $885*<br />
You’ll love it!<br />
– Wash/dry/fold laundry; neatly folded <strong>and</strong> right-side-out.<br />
– Includes personal bed <strong>and</strong> bath linens (sheets, pillowcases,<br />
towels, face cloths, etc.) in addition to your clothing.<br />
– Launderable, button-down dress shirts <strong>and</strong> blouses are<br />
pressed <strong>and</strong> returned on hangers.<br />
– Gentle care washing, drying <strong>and</strong> pressing<br />
– Skirts <strong>and</strong> dress pants, including khakis, returned pressed <strong>and</strong><br />
on hangers<br />
– Polo/Sport shirts returned pressed <strong>and</strong> on hangers<br />
– Sweaters returned pressed <strong>and</strong> on hangers<br />
– Professional dry cleaning <strong>and</strong> pressing<br />
– Plus get our Comforter <strong>and</strong> Blanket Plan FREE: A $70 Value<br />
In addition to wash/dry/fold service, dry cleaning, gentle care<br />
processing <strong>and</strong> pressing are provided at NO ADDITIONAL CHARGE. *<br />
Our “JUST THE BASICS” Plan: $735*<br />
For the more casual student<br />
– Wash/dry/fold laundry; neatly folded <strong>and</strong> right-side-out.<br />
– Includes personal bed <strong>and</strong> bath linens (sheets,<br />
pillowcases, towels, face cloths, etc.) in addition to your<br />
clothing.<br />
– Launderable, button-down dress shirts <strong>and</strong> blouses are<br />
pressed <strong>and</strong> returned on hangers.<br />
To avoid additional charges, we strongly encourage<br />
you to consider our “Look Sharp” Plan.**<br />
* Plans are designed for individual use only. Sharing of plans between students constitutes immediate<br />
forfeiture of service with no refund provided.<br />
** Our policy is to return it to you clean, whenever we can, regardless of which plan you have<br />
purchased.With our “Just the Basics” Plan, a credit card is required to be on file for payment of<br />
additional monthly charges. Garment care labels often call for gentle care <strong>and</strong>/or dry cleaning. As<br />
a professional cleaner, we have an obligation to follow a garment’s care label. For example: We<br />
dry clean all sweaters; All fleece requires gentle care washing; Certain styles of Under Armour®<br />
type performance gear require gentle care. These items incur additional charges under our “Just<br />
the Basics” Plan.<br />
Our Most<br />
Popular Plan!<br />
64 % 80 % World-class, environmentally-aware<br />
student laundry <strong>and</strong> dry cleaning<br />
service.<br />
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. <strong>15</strong>th, 20<strong>12</strong>.<br />
Savings<br />
Cancellation notices received <strong>after</strong><br />
Savings<br />
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 <strong>after</strong> Jan. 2, 2013.<br />
%<br />
A Healthy Lifestyle for Your Student<br />
- Students, <strong>and</strong> therefore their clothing, can be exposed to<br />
potentially infectious bacteria throughout their daily activities.<br />
- E&R has the exclusive distribution rights for BlockTeria, a fabric<br />
sanitizer that is added to each load we wash.<br />
- BlockTeria eliminates 99.999% of infectious contamination<br />
including MRSA-Staph.<br />
Gentle Care Processing vs. Dry Cleaning<br />
- Over 70% of items that we return to students on hangers are<br />
laundered <strong>and</strong> dried with a gentle care process, then pressed.<br />
- We launder all items that will get the same or better cleaning<br />
by using a gentle care laundry process vs. dry cleaning.<br />
Leaders in Sustainability<br />
86 % Water<br />
64 % Gas<br />
Savings<br />
86 % Water<br />
Savings<br />
64 % Students who use E&R generate the following utility savings with every load of<br />
laundry we do (savings based on independent Gas<br />
Savings study performed by TDK Engineering):<br />
Savings<br />
80 % Electricity<br />
Savings<br />
<strong>Order</strong><br />
Now<br />
Password<br />
CS70<br />
Printable <strong>Order</strong> Form On Last Page<br />
Less than $5<br />
more per week!<br />
<strong>Suffield</strong>
Easy to Carry<br />
Separate<br />
Compartment for<br />
your Socks <strong>and</strong><br />
Delicates<br />
Since 1921<br />
Introducing Our New,<br />
Duffle-Style Bag!<br />
Sewn in Hook<br />
Lets Bag Double<br />
as a Hamper<br />
www.Facebook.com/E<strong>and</strong>RLaundry<br />
E<strong>and</strong>RLaundry<br />
Local Business . Manchester, New Hampshire<br />
Keeps Clothes Neat <strong>and</strong> Secure<br />
Holds 25% More Than Our Old Style Bag!<br />
Robert, Groton Student<br />
E&R has made my life so much less stressful. I see people walking to do laundry<br />
all the time when I need to spend my time elsewhere. Thanks to E&R, I have an<br />
amazing luxury to spend my time the way I need to. All of my clothes are always in<br />
neat condition when returned which allows me to have a closet free of clutter while<br />
none of my time is wasted folding <strong>and</strong> ironing. Thank you, E&R!<br />
FAQs<br />
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.<br />
Please see the enclosed descriptions which will explain our plans in detail for you.<br />
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.<br />
How do you k<strong>now</strong> which bag belongs to my student? As you can see in the picture above, each bag is personalized with a printed label. In<br />
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.<br />
If I’m signed up for the Comforter <strong>and</strong> Blanket Cleaning Plan, how do I fit that in my bag along with all of my clothes? Not to<br />
worry, we provide disposable, one-time-use bags for your comforter <strong>and</strong> blanket. You’ll get your first one when we give you your other laundry<br />
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<br />
you can repeat the process the next time you want them cleaned.<br />
If I’m signed up for the Look Sharp or Just the Basics plan, will you also clean my personal sheets, pillow cases <strong>and</strong> towels?<br />
Yes, both plans include cleaning of your personal sheets, pillow cases <strong>and</strong> towels <strong>and</strong> they can go right in your laundry bag with the rest of your<br />
clothes.<br />
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<br />
clothes when we check them in <strong>and</strong> again as we fold your laundry <strong>and</strong> put it back in your bag. Any clothes that are returned on a hanger get<br />
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,<br />
just like we do with the laundry bag.<br />
Who is actually washing <strong>and</strong> dry cleaning my student’s clothes? All of the cleaning<br />
is performed in our state-of-the-art facility by personnel who have decades<br />
of experience in all areas of our operation. Because we control 100% of<br />
the work, you can count on us to be 100% responsible for making sure<br />
everything is done right.<br />
How do I sign up? <strong>Order</strong> online ! You can also register for service via<br />
phone, email, fax or postal mail. See the enclosed brochure for details on how<br />
to take advantage of whatever option works best for you.<br />
How will I k<strong>now</strong> how to get started upon arrival at school? Once<br />
you have registered, we will notify you via email as to our bag distribution<br />
process at your particular school. We also staff a table on campus during<br />
student registration days to h<strong>and</strong> out laundry bags <strong>and</strong> answer questions<br />
about getting started.<br />
What if I have a question that isn’t answered in these FAQs<br />
or anywhere else on your brochure? Please be sure to contact our<br />
Customer Service Team if you require further information. Our contact<br />
information is on the Post-it Note to the right.<br />
Customer Service<br />
We’re here to help!<br />
As always, if you have questions that are<br />
not covered here, we are just a phone<br />
call or an email away.<br />
Warm Regards<br />
Cindy <strong>and</strong> Sarah<br />
Cindy Proctor <strong>and</strong> Sarah Robinson<br />
Tel: 800-243-7789 Ext. 713 <strong>and</strong> Ext. 714<br />
Email: Info@E<strong>and</strong>RCleaners.com<br />
About<br />
E&R -The Campus Laundry<br />
specializes in servicing the<br />
wash/dry/fold laundry…<br />
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Scan to “Like” Us<br />
WIN GREAT PRIZES<br />
Like . Comment . January 16 at 4:32pm<br />
Shannon, Choate <strong>and</strong> Barnard College Mom<br />
Thanks E & R! You have been the saving grace for our family! We have one<br />
daughter at Choate <strong>and</strong> one at Barnard. Both love having your laundry service take<br />
that worry off of their minds. They say it is awesome to be able to send out a bag of<br />
dirty clothes <strong>and</strong> have clean ones “magically” reappear! We love E&R!!<br />
Like . Comment . January <strong>12</strong> at 6:47pm<br />
LA, Salisbury Mom<br />
E&R Laundry service is by far the best service being offered to students!! Not<br />
only is it convenient but the service my son receives has been top notch. The staff<br />
have been excellent to work with <strong>and</strong> being from another country it gives me piece<br />
of mind k<strong>now</strong>ing that my son never has to worry about his clothing. Thank you to<br />
everyone at E&R.<br />
A very grateful Salisbury Mom<br />
Like . Comment . January <strong>12</strong> at 4:44pm<br />
Wendy, Colby College Mom Mom<br />
My son Nicholas just doesn’t have time in his busy schedule for laundry. Thank<br />
heavens for E&R. I’m really not sure what he would do or how he would manage<br />
without you.<br />
Like . Comment . January <strong>12</strong> at <strong>12</strong>:01pm<br />
Debra, Berkshire Mom<br />
2 TEENAGE BOYS, 2 DORM ROOMS, 6 JV AND VARSITY SPORTS, <strong>12</strong><br />
CLASSES PLUS CHORUS & GREENSLEEVES! HOW MANY KHAKIS, DRESS<br />
SHIRTS, SWEATERS AND BLAZERS DOES IT TAKE TO GET THRU THE<br />
YEAR…THANK HEAVENS FOR E & R LAUNDRY! YOU MAKE MIRACLES<br />
EVERY DAY. THANK YOU, BERKSHIRE SCHOOL MOM!<br />
Like . Comment . January 11 at 6:57pm<br />
Cole, <strong>Suffield</strong> Student<br />
E&R laundry has been a HUGE blessing helping me get through the school year<br />
at <strong>Suffield</strong> <strong>Academy</strong>. I don’t k<strong>now</strong> what I would do without you! Thank you!<br />
Like . Comment . January 11 at 8:42pm<br />
Leslie, Wesleyan University Mom Mom<br />
My son goes to school <strong>15</strong> hours away from home <strong>and</strong> this service has been<br />
Great! Definitely recommend your service!<br />
Like . Comment . January 11 at 9:00pm<br />
WIN FREE SERVICE<br />
WIN COOL SWAG<br />
Printable <strong>Order</strong> Form On Last Page
06078 • (860) 668-73<strong>15</strong> • Fax (860) 668-2966<br />
Since 1921 Since 1921<br />
Register online at www.TheCampusLaundry.com using password CS7Ø<br />
"Look Sharp"<br />
Our Most<br />
Popular<br />
Plan!<br />
Less than $5<br />
more per<br />
$885<br />
( <strong>Order</strong> All pricing <strong>now</strong> is <strong>and</strong> for <strong>save</strong>! the full <strong>$920</strong> academic <strong>after</strong> 8/<strong>15</strong>/<strong>12</strong> year. )<br />
( # 650) week!<br />
( # 652)<br />
In addition to wash/dry/fold service, dry<br />
cleaning, gentle care processing <strong>and</strong> pressing<br />
are provided at NO ADDITIONAL CHARGE.<br />
"Just The Basics"<br />
$735<br />
( <strong>Order</strong> All pricing <strong>now</strong> <strong>and</strong> is for <strong>save</strong>! the full $770 academic <strong>after</strong> 8/<strong>15</strong>/<strong>12</strong> year. )<br />
A credit card is required to be on file for the billing of incidental charges:<br />
Card #<br />
exp. date CCV# *<br />
ADDITIONAL PLANS<br />
"Fresh" Comforter & Blanket Cleaning - Free<br />
( We'll clean your own comforter <strong>and</strong>/or blankets up to five<br />
# 655)<br />
times during the school year. (Free with “Look Sharp” plan)<br />
"Fresh" Bed & Bath Linen Rental Plan - $135<br />
( Four (4) Flat sheets, two (2) pillow cases, <strong>and</strong> six (6) large<br />
# 654)<br />
(24" x 48") top quality bath towels to use <strong>and</strong> send for<br />
cleaning as needed.<br />
"Fresh" Towel Rental Plan - $75<br />
( Four (4) large (24" x 48") top quality bath towels to use<br />
# 653)<br />
<strong>and</strong> send for cleaning as needed.<br />
NAME OF CARDHOLDER (Please Print)<br />
SIGNATURE<br />
ADDITIONAL PLANS<br />
( # 655)<br />
( # 654)<br />
( # 653)<br />
"Fresh" Comforter & Blanket Cleaning - $70<br />
"Fresh" Bed & Bath Linen Rental Plan - $135<br />
"Fresh" Towel Rental Plan - $75<br />
PLEASE PRINT Year of Graduation? Gender? Male Female (Check one)<br />
STUDENT NAME (AS REGISTERED AT SCHOOL) FIRST/LAST<br />
STUDENT CELL PHONE<br />
STUDENT EMAIL<br />
CELL PHONE CARRIER<br />
PARENT OR GUARDIAN (PLEASE PRINT) FIRST/LAST PARENT PHONE PARENT EMAIIL<br />
billing ADDRESS (STREET)<br />
CITY STATE ZIP COUNTRY<br />
Did this student use an E&R service at <strong>Suffield</strong> academy in the 2011-20<strong>12</strong> academic year? YES NO (Check one)<br />
Payment Method: n Same as Above n MASTERCARD n VISA n DISCOVER -or- n Check Make checks payable to E&R Cleaners<br />
NAME OF CARDHOLDER (Please Print)<br />
SIGNATURE<br />
- - -<br />
CARD# exp. date CCV# **<br />
For Office Use Only Bag# CS<br />
** Your CCV# is the last three digits of the number in the signature section of your card<br />
Register online at www.TheCampusLaundry.com using password CS7Ø<br />
Phone <strong>Order</strong>s: 800-243-7789 inside the U.S.; Mail Registration Form to: E&R Laundry <strong>and</strong> Dry Cleaners<br />
603-627-7661 outside the U.S.<br />
School Department<br />
Fax <strong>Order</strong>s: 603-627-7644<br />
80 Ross Avenue<br />
Manchester, NH 03103-9962<br />
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<br />
cancellation request that is received no later than Oct. <strong>15</strong>th, 20<strong>12</strong>. Cancellation notices received <strong>after</strong> that date, but before Jan. 2, 2013 will receive refunds for the second semester only, minus<br />
the $69 operations cancellation charge. There will be no refunds issued <strong>after</strong> Jan. 2, 2013.<br />
Register by<br />
August <strong>15</strong>th<br />
<strong>and</strong> Save!
suffield academy<br />
<strong>Suffield</strong>, Connecticut / 860.386.4400<br />
JULIE’S LAUNDRY SERVICE<br />
919 Enfield Street (Rt. 5) Enfield, CT 06082 phone (860) 745-4522 cell (860) 394-8051<br />
Please return this form to the address above or by email. jpoonlai@yahoo.com<br />
<strong>Suffield</strong> <strong>Academy</strong> Students Individual Laundry Account Sign-up Form 20<strong>12</strong>-2013 School Year (9/6/20<strong>12</strong>-5/30/2013)<br />
Student Name: ______________________________________________ Billing Person: ______________________________________________<br />
Dorm: ____________________________________________________ Address: ___________________________________________________<br />
Grade: ____________________________________________________ __________________________________________________________<br />
Phone: ___________________________________________________ Phone: _________________email:_______________________________<br />
Email: ____________________________________________________ [ ] Check enclosed. $__________________________________________<br />
Please make checks payable to Julie’s Laundromat & Cleaners<br />
[ ] Discover, Visa & Mastercard add 4% service charge.<br />
#______________________________________Expires: _____________<br />
There are 5 plans to choose from:<br />
Each plan includes 2 Laundry Bags <strong>and</strong> 2 Garment Bags, except Plan #5.<br />
The bags are yours to keep. There is no extra charge if you take them home in May.<br />
[ ] Plan #1 $685.00<br />
• Wash-Dry-Fold <strong>and</strong> Hang.<br />
[ ] Plan #2 $825.00<br />
• Wash-Dry-Fold <strong>and</strong> Hang.<br />
• Wash <strong>and</strong> Press dress shirts, blouses, slacks, skirts, <strong>and</strong> dresses.<br />
[ ] Plan #3 $375.00 Minimum Charge<br />
• Wash-Dry-Fold by the pound. $1.00/lb, minimum <strong>12</strong> lb.<br />
• Pressing, dry cleaning, leather cleaning <strong>and</strong> sewing services are charged itemized.<br />
• A statement will be sent home <strong>after</strong> the school year ends if the amount used is over $375.00.<br />
[ ] Plan #4 $885.00<br />
• Wash-Dry-Fold <strong>and</strong> Hang.<br />
• DRY CLEAN & Wash <strong>and</strong> Press dress shirts, blouses, slacks, skirts, dresses, suit jackets, ties <strong>and</strong> sweaters.<br />
[ ] Plan #5 $300.00 (Must sign up early & must sign up in conjunction with any of the above plans)<br />
[ ] Renewal $50.00 (Your Linen Package stored for the summer, cleaned <strong>and</strong> delivered to your dorm upon your arrival in Sept.)<br />
• Linen Rental - Package includes: New 2 Blankets, 2 Sheet Sets, 4 Towel Sets.<br />
• Wash, Dry & Fold with your laundry. This set of linen is purchase for your use only for the academic year.<br />
• For your convenience, we pre-wash the new linens so that you can use them immediately in your dorm.<br />
√ Sign up by August <strong>15</strong>, 20<strong>12</strong> <strong>and</strong> your welcome package will be ready for you at registration.<br />
√ First pick up service is on Sept. 6th, 20<strong>12</strong> around 11:30am at the Student Union Locker Room.<br />
√ DELIVERY DAYS are BOTH MONDAYS & THURSDAYS.<br />
When you drop off laundry on Mondays your clean laundry will be returned to your dorm on Thursdays.<br />
When you drop off laundry on Thursdays your clean laundry will be returned to your dorm on Mondays.<br />
√ We do each student’s laundry individually <strong>and</strong> with care. Sorry, we do not h<strong>and</strong> wash. We are not responsible for any lost articles, garments that<br />
run or garments that do not hold up in the cleaning process.<br />
√ For best results: Initial your garments, turn garments right side out, unbutton shirts, empty pockets, <strong>and</strong> don’t mix in wet<br />
items with your laundry. For quick returns: Separate dry cleaning from laundry.<br />
√ Refund policy for early termination of laundry Plan 1, 2, <strong>and</strong> 4 are to convert into Plan 3. You will be charged $375.00 or what you used plus a<br />
$50.00 service fee, which ever is more. No refunds for plan #5. No refunds <strong>after</strong> January 1st, 2013.<br />
Thank you for choosing Julie’s; we have served <strong>Suffield</strong> <strong>Academy</strong> students since 1991 with quality service <strong>and</strong> care. We are proud to<br />
celebrate 27 years in business. We look forward to serving your laundry needs for the coming academic year.
Dear Sufüeld <strong>Academy</strong> Parents <strong>and</strong> Students:<br />
First we want to give a very special thanlis to<br />
Suffreld <strong>Academy</strong> who have supported us since lÐ1.<br />
Thank you for giving us the opportunity to serve all<br />
yoru laundry needs. We appreciate <strong>and</strong> value ou¡<br />
Julie's Laundromat & Cleaners<br />
Business Hours:<br />
Mondays to Saturdays 7:30am to 9:00pm<br />
Sundays 7:30am to 7:00pm<br />
Closed on New Year Day, Easter Sunday, Memorial Day,<br />
Independence Day, Thanksgiving Day <strong>and</strong> Christmas Day.<br />
relationship wittr <strong>Suffield</strong> <strong>Academy</strong> <strong>and</strong> we are proud<br />
to celebrate 27 yearc in business since 1985.<br />
In thinking GREEN, the fabric laundry &<br />
garment bags are a big help to reduce plastic bag<br />
waste. Therefore, we will continue to use them this<br />
yeaf.<br />
Our bags are color coded to your dorm. If<br />
you don't have your dorm assignments yet, you should<br />
stilt sigr up early <strong>and</strong> we will get the dorm info from<br />
Suffreld <strong>Academy</strong> to prepare your welcome package.<br />
Ncrv spccial fcaturc fnr Pl¿n #5 Lincn<br />
{<br />
Rent¿ls. The linen rental service is $300 for initial<br />
sign ups with all new linens washed <strong>and</strong> ready to<br />
use. Each annual renewal is $50.00 which includes<br />
storage for the summer, cleaned <strong>and</strong> delivered to your<br />
dorm the following school year. This plan must be<br />
used in oonjunction with Plan #1.#2, #3 or #4. This<br />
plan will help lighten your load on move-in day.<br />
Please read through <strong>and</strong> keep this brochu¡e<br />
for future reference as it contains information of our<br />
services. Ifyou still have questions, please don't<br />
hesitate to contact us by phone or email.<br />
We hope you have a wonderful surnrner, We<br />
look fonvard to serving all your laundry needs. See<br />
you at registration.<br />
Sincerely,<br />
Julie <strong>and</strong> Staff<br />
Directions from Suffreld Acaderny:<br />
Come visit us if you are in the areo.<br />
1 : Staf out going NORTH on N IVÍAIN ST / CT-75 toward<br />
SILES RD.0.8miles<br />
2: Tum RIGIIT onto MAPLETON AVE / CT-190. 0.5 miles<br />
3: TUM SLIGFIT RIGHT ONIO THOMPSONVILLE RD /<br />
CT-190. 1.1miles<br />
4: Tum RIGIIT onto EAST ST N / CT-<strong>15</strong>9 / CT-190. 0.6 miles<br />
5: Turn LEFT onto CT-190. 0.6 miles<br />
6: Take üreramp towanlUS-5 /ENFIELD. 0.1 miles<br />
7: Tu¡n SLIGHT LEFT onto FREW TER. 0.1 miltx<br />
8: TumLEFT onto ENFIEI-,D ST /US-5. 0.4 miles<br />
9: Arrive at Julie's Laundromat & Cleaners,<br />
919 Enfrcld St, Enfield, CT 06082, US<br />
Total Est. Time: l0 minutes<br />
Total Est. Distance: 4 65 miles
Su eld <strong>Academy</strong> Students Laundry Plans<br />
Julie's Laundry Service at Suflield <strong>Academy</strong> since 1991<br />
Julie's 5 Laundry Service Plans:<br />
<strong>Suffield</strong> <strong>Academy</strong> 20<strong>12</strong>-2013 School Year<br />
Sign up by August l5r20l2 <strong>and</strong>you will<br />
receive your welcome package of 2 fabric laundry<br />
<strong>and</strong> garmenL bags at regislration. These 4 bags are<br />
yours to keep at the end ofthe year.<br />
Julie's Cleaners wil[ be at registrationon9/4,9/6<br />
&.917/20<strong>12</strong> for a meet & greet, <strong>and</strong> to answer any<br />
çestions or concerns you may have.<br />
We offer DOUBLE THE SERVICE with pick<br />
ups in the Student ion Locker Room <strong>and</strong> drop<br />
offs in your dorm on both Mondays <strong>and</strong><br />
Thursdays. First day of service will begin on<br />
Thursday 9/6/<strong>12</strong> @11:30am. This is a special<br />
start date for the Varsity C<strong>and</strong>idates <strong>and</strong><br />
Proctors.<br />
We tn¡st an honor system. If you miss a pick up,<br />
we underst<strong>and</strong> you will have more laundry the<br />
next time.<br />
We do each student's laundry individually <strong>and</strong><br />
with care. Sorry we do not h<strong>and</strong> wash. We do not<br />
take responsibilþ for any lost articles, garments<br />
that nur or do not hold up in the cleaning process.<br />
For best results: Initial your gaments. turn all<br />
garments right side out, unbutton shirts, empty<br />
pockets <strong>and</strong> don't mix in wet items with your<br />
laundry.<br />
We offer free minor sewing sen'ice <strong>and</strong> special<br />
laundry needs. Just include insfuctions with your<br />
phone number <strong>and</strong> we will do our best for you.<br />
Julie's st¿ffis very honest. Over the years we have<br />
found <strong>and</strong> retumed many wallets, keys, MP3s, cell<br />
phones, credit cards, money <strong>and</strong> other valuables to<br />
their owners.<br />
Please THINK GREEN by using both laurdry<br />
& garment bags every time. We also encourage the<br />
re-use of good hangers. Together we can generate<br />
less trash for our environment.<br />
Extra charge items not included in your plan will be<br />
charged to your school account or invoiced home at<br />
thc cnd ofthc school ycar.<br />
Refund policy for early termination of laundry<br />
Plans #1, #2, &.#4 is ûo convert to Plan #3. You<br />
will be chargcd $375.00 or your itcmize usage plus<br />
a $50.00 service fee which ever is more. No<br />
refunds for Plan #5. There are no refirnds <strong>after</strong><br />
January lst,2013.<br />
Got laundry?<br />
Julie's Laundromat & Cleaners can help!<br />
From Sept. 6th, 20<strong>12</strong> to May 30th, 2013<br />
Plan #1 S685.00 (2 laundry & 2 garment bags)<br />
o Vy'ash-Dry-Fold <strong>and</strong> Hang.<br />
Plan #2 $825.00 (2 laundry & 2 garment bags)<br />
o Vy'ash-Dry-Fold <strong>and</strong> Hang.<br />
. Wash <strong>and</strong> Press dress shi¡ts, blouses, slacks, ski¡ts <strong>and</strong><br />
dresses.<br />
Plan #3 $375.00 Minimum Charge<br />
(2 lamdry & 2 garment bags)<br />
¡ Wash-Dry-Fold; $1.00/lb, minimum l2lbs.<br />
o F'ressing, dry cleaning, leather cleaning <strong>and</strong> sewing<br />
services are charged itemized. A statement will be sent<br />
home <strong>after</strong> the school year ends if the amount used is<br />
over $375.00.<br />
Plan #4 $885.00 (2 laurdry & 2 garment bags)<br />
o Wash-Dry-Fold <strong>and</strong> Hang.<br />
o Wash <strong>and</strong> Press dress shirts, blouses, slacks, skirts, <strong>and</strong><br />
dresses.<br />
o Dry Cleanjackets, ties, sweaters, slacks, skirts & dresses.<br />
Plan #5 5300.00 Must sign up early <strong>and</strong> in conjunction<br />
with any one ofthe above laundry plans.<br />
o Linen Rental Sen¡ice (Package includes: All new 2<br />
Blankets, 2 sheets sets, 4 towel sets. These linens are<br />
assigned to ¡rou for the academic year. For your<br />
convenience, these items will be washed <strong>and</strong> ready for<br />
you to use upon your a¡rival.<br />
o Wash, Dry <strong>and</strong> Fold with your launclry.<br />
o Annual Renewal $50.00<br />
The above plans are priced for ONE studentfs<br />
normal usage only. NO Limits per pick up for<br />
your convenience but we appreciate your<br />
underst<strong>and</strong>ing <strong>and</strong> cooperation to this honor<br />
system. Together we can keep prices down.<br />
Thank you!
[<br />
suffield academy<br />
[ <strong>Suffield</strong>, Connecticut / 860.386.4400<br />
20<strong>12</strong>/13 student forms<br />
ID#<br />
date of birth<br />
June 5, 20<strong>12</strong><br />
To:<br />
New International Students <strong>and</strong> Parents<br />
From:<br />
Charles Cahn III, Headmaster<br />
Welcome to <strong>Suffield</strong>!<br />
I am writing to tell you about plans for arrival <strong>and</strong> orientation at <strong>Suffield</strong> this fall. We invite all new international students to join us a day early for a special<br />
orientation program beginning on Thursday, September 6. This includes all students who reside outside of the continental U.S., regardless of nationality, as<br />
well as students residing in the U.S. who are not U.S. citizens. Our international families have special needs <strong>and</strong> interests at <strong>Suffield</strong>, <strong>and</strong> we have designed<br />
this program to address these issues.<br />
The orientation schedule below outlines the plans for Thursday, September 6, <strong>and</strong> Friday, September 7. Complete details for the orientation will be available<br />
at registration. I am looking forward to greeting you in September.<br />
Date Time Event<br />
Thursday,<br />
September 6 9:30-11:00 A.M. Registration Centurion Hall<br />
6:00-9:00 P.M. Orientation for Students S. Kent Legare Library<br />
Friday,<br />
September 7 Morning Orientation<br />
Review of Rules<br />
Placement Testing<br />
[<br />
FORM XX DUE: 07.<strong>15</strong>.<strong>12</strong><br />
[