Dear Parent or Guardian,

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1 Dear Parent or Guardian, This summer may be a period of transition for you and your child. For a lot of our students it may even be the first time they are taking the lead in their personal care, including medical care. In our experience, we find that it is helpful to talk with your child about expectations before the program and discuss how to can manage stressors and health challenges that may arise. Although leaving home and living in an entirely new environment, even for a short period of time, is usually immensely exciting and satisfying, it can also be stressful. Please note that Barnard College does not offer counseling or medical services to students over the summer months. Please consult with your health care provider to make arrangements to manage all ongoing health issues while your child is participating in the program. If they are taking daily prescribed medication, please discuss the importance of maintaining their medication regimen while away and make sure that they have enough for the duration of the program. If your child has a diagnosed disability that has the potential to affect a daily life activity, we kindly ask that you share that with us in the following Health Questionnaire. The Office of Pre- College Programs will work with self-identified students with disabilities to identify reasonable accommodations. If a disability is not disclosed, we may not be able to provide accommodations as needed. Over the next two months please sit down to discuss their summer program and their expectations as well as yours as a family. In order to make the most of their time away from home develop a plan for self-care and how to address any potential concerns that may arise. Please plan to check in with your child regularly. Life has shown me that thorough preparation makes its own luck therefore it is imperative that we all PLAN together for a successful and safe experience at Barnard and in New York City for all of our students. Thank you for your consideration of these matters. I look forward to meeting you all at the Gates on Opening Day! Aleschia D. Johnson, Director

2 Summer Program Health Questionnaire PLEASE RETURN THIS FORM BY FRIDAY, MAY 31 ST. VIA MAIL TO: OFFICE OF PRE COLLEGE PROGRAMS 3009 BROADWAY NEW YORK, NEW YORK Students: Welcome to your summer program at Barnard College, Columbia University. Before you begin your program on campus, it is necessary that you provide Columbia Health with (1) proof of immunity to MMR (2) accurate and complete health-related information; (3) if you are under 18, written authorization by your parent or guardian for provision of medical treatment and (4) documentation of health insurance coverage. This information will be kept in strictest confidence by the program and will be shared only when necessary. A copy of this form will remain on file at Columbia Health, so that we will be prepared to address any medical conditions which may arise. All sections of this form must be completed. Name of your summer program(s): FN: LN: Date of Birth Gender: Address: Cell Phone Number: MEDICAL/ SURGICAL HISTORY: ALLERGIES: Please list all substances you are allergic to including, but not limited to, foods and medications. Medication/Food/Other Reaction Treatment (if any)

3 DIAGNOSES: Please list any medical or mental health diagnoses. If you do not have any, please write NONE. Name of Condition Diagnosis Date MEDICATIONS: Please list below all medications you are taking. Please indicate the condition for which you are taking the medication. Include frequency and dosage. Please bring the total amount of medication you will need while at your summer program. Columbia Health providers do not prescribe medication for students whose conditions are managed by outside treatment providers. Medication Name Condition for the Medication Dosage and Frequency If you will need to have Columbia Health store and/or administer any medication for you, please contact Columbia Health Medical Services directly no later than two weeks prior to your arrival to request the necessary approval forms. Columbia Health Medical Services will review every request for feasibility and appropriateness and will notify you before you arrive once a decision has been made. Please see contact information directly below. Columbia Health reserves the right to decline any request that has not followed this process. To request approval forms for medication administration, contact: Medical Services, Columbia Health Columbia University MC West 114 th Street New York, NY Phone number: , ext 4 Fax number:

4 IMMUNIZATIONS Students admitted to the summer program are required to provide proof of immunity to Measles, Mumps and Rubella (MMR) by returning the MMR Immunization form (which you will receive via ) to office of Health Services at Columbia University. In addition to providing documentation of immunity to MMR, we recommend that young adults be fully immunized against Hepatitis B and Varicella (Chicken Pox) Tdap, Polio, Hep A & B and HPV. HEALTH INSURANCE INFORMATION: All students are expected to have health insurance coverage, which includes emergency care and major medical coverage for hospitalization in New York State. Students are required to bring proof of insurance coverage with them. Please provide your health insurance coverage information below and a photo copy of the front and back of your card and attach that copy to this form. Insurance Carrier: Subscriber s name: Relationship to Student: Insurance Policy or Group Number: Insurance Company Telephone Number: AUTHORIZATION FOR MEDICAL TREATMENT OF STUDENT UNDER 18 YEARS OF AGE (Signature of parent or guardian is required if the student will be under 18 years of age on the first day of the program.) I authorize and grant permission to Columbia Health to both evaluate and render medical treatment to the student named on this form, including but not limited to, ordering medically necessary tests, administering appropriate medications, providing prescriptions and referrals, and if necessary transporting the student to the hospital for a higher level of care. Signature: Date: Relationship to Student:

5 AUTHORIZATION TO SEEK MEDICAL ATTENTION FOR STUDENT UNDER 18 YEARS OF AGE (Signature of parent or guardian is required if the student will be under 18 years of age on the first day of the program) I authorize the staff of the Barnard Pre-College Programs and any other entity offering educational services in conjunction with the Barnard Pre-College Programs students to seek emergency medical attention for the student named on this form. Signature: Date: Relationship to Student:

6 Columbia University Measles, Mumps, and Rubella Form Federal Law mandates that we cannot accept records via for security and privacy reasons. I. STUDENTS COMPLETE THIS SECTION New York State Public Health Law 2165 and University Policy REQUIRES all students born on or after JANUARY 1, 1957 prove immunity to measles, mumps, and rubella. Student Name: Columbia ID (PID or UNI): Last/Family First Middle Initial N/A Birth Date: Phone #: Personal ID or University Network ID Month Day Year Personal CU School Affiliation: _ B _ a _ r _ n _ a _ rd P _ r _ e _ -Co _ lle _ g _ e II.HEALTH CARE PROVIDERS COMPLETE THIS SECTION All of section A or section B below must be completed by a physician or health care provider. Section A: MMR (Measles, Mumps, and Rubella) Month Day Year 1st MMR DOSE: Administered after the first birthday AND after 1/1/1972 and 2nd MMR DOSE: or 2nd Live Virus Measles Dose: Administered at least 28 days after 1st dose Section B-PART 1: MEASLES 1st Live Virus Dose: Administered after first birthday 2nd Live Virus Dose: Administered at least 28 days after 1st dose History of Illness documented by Health Care Provider Immunity Proven by Serologic Testing MUST SUBMIT COPY OF LAB REPORT Month Day Year Section B-PART 2: MUMPS Live Virus Dose: Administered after first birthday AND after 1/1/1969 History of Illness documented by Health Care Provider Immunity Proven by Serologic Testing MUST SUBMIT COPY OF LAB REPORT Month Day Year Section B-PART 3: RUBELLA (German Measles) Live Virus Dose: Administered after first birthday AND after 1/1/1969 Immunity Proven by Serologic Testing MUST SUBMIT COPY OF LAB REPORT Note: History of Illness is NOT acceptable Month Day Year The information on this form is accurate to the best of my knowledge. Physician/Provider Name (Please Print) Signature Physician/Provider Stamp Lic. #

7 Measles, Mumps, and Rubella Form Instructions and Explanations Instructions Students: Complete the top portion of this form. Once your physician or health care provider has completed this form or you have copies of supporting documentation, make a copy for your records and return the originals to the Barnard Pre-College Office via fax ( ) or mail to Barnard Pre-College, 3009 Broadway, NY, NY We will be unable to process your form without your name, Birthdate, health care provider s name and provider s signature. Physician or other Health Care Provider: Complete all required information. Documentation of two (2) MMR vaccines (or equivalent) is required: the first administered after the first birthday and the second administered at least 28 days after the first vaccine. Laboratory results must be provided if immunity is demonstrated by serological testing. If there is no supporting documentation, this form will NOT be processed without a health care provider s name and signature. Explanations of Supporting Documentation 1. Immunization Documentation from Another School Students who have attended another school in the United States may submit a copy of those immunization records to prove immunity to measles, mumps, and rubella. Once you have obtained a copy of your documentation, please complete the top portion of this form and attach to the copy of your immunization record. Since requirements vary by state and country, your record is reviewed for compliance with New York State and University requirements. It is important for you to maintain a copy, as the forms are often illegible or lack identifying information required to process the documentation. 2. Vaccine History Provide a certificate of immunization verifying the date of the disease, or the administered measles, mumps, and rubella vaccines. This includes documents such as: A certificate from a licensed physician A migrant health record A community health plan record An immunization record card signed by a physician, a physician s assistant, or nurse practitioner You must also complete the student section of this form and submit it along with your immunization record. Please note that all immunizations must have been received after your first birthday. 3. Document History of Illness If you have been diagnosed by a physician with having had measles and/or mumps, this is acceptable proof of immunity. The physician must enter the dates of initial diagnosis on this record form. Note: A diagnosis of previous rubella disease is not acceptable proof of immunity under New York State Health Code. 4. Immunity Proven by Serological Testing Immunity to all of the three diseases may be proven by blood test for antibodies. You must submit a copy of the actual laboratory report with this form. If you have any questions please Please retain a copy for your records. health.columbia.edu/immunization

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