Greetings,

On behalf of Health Services, congratulations and welcome to ! We look forward to you becoming part of our campus community!

Please see the attached packet of Health Record requirements, and carefully review the checklist provided. A physical exam by your Primary Care Physician is mandated within the 2020 calendar year, if you received a physical in 2019 check with your insurance provider as most companies allow a physical once every calendar year starting January 1st. Please note that doctors' offices are extremely busy, and it may be difficult to schedule an appointment on short notice. We highly recommend that you call your doctor as soon as possible to schedule your physical exam if you haven't already done so, and remember to have as much information on the form filled in as possible.

NON-ATHLETES: If you have any questions or medical concerns, please contact Health Services at 508-213-2238. Please note that Health Services office hours are minimal during the summer, but messages are checked frequently and someone will get back to you as soon as possible. If you need immediate assistance, please contact Student Services at 508-213-2480. Non-athletes must mail back their completed health forms by Friday, August 7th, or bring them to the nurse's station on move-in day.

ATHLETES: If you will be participating in intercollegiate sports, NCAA regulations mandate that you have a physical within 6 months of arriving on campus. If you have any questions, please contact Tim Bennett, Head Athletic Trainer, at 508-213-2183. Athletes must mail back their completed health forms by Monday, August 3rd. If you do not have confirmation that the Health Center or Sports Medicine has received your packet, please make copies of your forms and bring them to your team’s check-in to guarantee participation clearance.

Incomer’s Checklist Sincerely, - Print out this entire packet

Katherine Nicoletti RN - Complete Health Record and Student Health History forms Director of Health Services and College Nurse Health Services - Have your Physician complete the Physical and Phone: 508-213-2238 Immunization forms

Fax: 508-213-2134 - Make a copy of your current Insurance card (Front [email protected] & Back)

- Copy all completed forms (One for Health Center Timothy R. Bennett MBA ATC/L and one for Athletics)

Head Athletic Trainer - Send all copies to Nichols College in envelope. Athletics Health Care Administrator (121 Center Rd, Dudley, MA 01571-5000) Department of Athletics Phone: 508 213-2183 *If you are an Athlete* Fax: 508-213-2446 Complete attached AT Waiver and Sickle Cell [email protected] Waiver forms. (pgs. 10-12)

Make sure Physical date is within 6 months from Nichols College arriving on campus. (Required by NCAA) Learn. Lead. Succeed.

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FOR OFFICE USE ONLY HEALTH RECORD

MAIL COMPLETED RECORD TO: Office of Health Services Nichols College P.O. BOX 5000

Dudley, MA 01571

NAME: DATE OF BIRTH: (LAST) (FIRST) (MIDDLE INITIAL) CELL PHONE #: ( ) HOME PHONE#: ( ) STUDENT ID#:

HOME ADDRESS: (STREET)

(CITY) (STATE) (ZIP)

EMERGENCY CONTACT INFORMATION

PARENT/GUARDIAN: PARENT/GUARDIAN: RELATIONSHIP: RELATIONSHIP: ADDRESS: ADDRESS:

EMERGENCY PHONE: EMERGENCY PHONE:

INSURANCE INFORMATION (All students are required by Sate Law to have Health Insurance. Insurance must be current and valid.) *PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD FRONT AND BACK. INCLUDE SECONDARY INSURANCE AND PRESCRIPTION INFORMATION*

NAME OF INSURANCE COMPANY: PHONE #: POLICY #: GROUP #: SUBSCRIBER: SUBSCRIBER DOB: EMPLOYER:

PLEASE CIRCLE ALL THAT APPLY: RESIDENT COMMUTER FRESHMAN TRANSFER RE-ADMIT (If applicable, please list the dates you were a previous student at Nichols______) PREVIOUS COLLEGE: (If applicable, please list the dates enrolled at previous college______) PLEASE INDICATE IF YOU WILL BE PARTICIPATING IN AN INTERCOLLEGIATE SPORT: YES NO UNSURE WHAT SPORT(S) WILL YOU BE PARTICIPATING IN? (LIST)

CONSENT FOR TREATMENT I, the above named student give informed consent for the routine care through the Nichols College Office of Health Services, Mental Health Services and if an Athlete the Nichols College Athletic Department and in the event of an EMERGENCY, give permission to the above named departments and its affiliated hospital to secure for this student appropriate treatment, including orders for surgery and anesthesia if necessary. Your signature also allows Health Services, Mental Health Services and if an athlete the Athletic Department to release any PERTINENT medical and mental health information (i.e., allergies, immunization status, special medical conditions or mental health concerns) to Student Services, Advising Services, Res. Life, Academic Services and Public Safety. These entities will be allowed to share information as determined appropriate to assure the safety and well-being of the student. STUDENT SIGNATURE X______

PARENT OR GUARDIAN SIGNATURE X______(Required if student is 18 or under)

Nichols College 2 Learn. Lead. Succeed

STUDENT HEALTH HISTORY FORM Please complete this form before going to your Physician for examination.

NAME: DATE OF BIRTH: (LAST) (FIRST) (M.I) PERSONAL HISTORY: Have you ever had or have now? (PLEASE CHECK ALL THAT APPLY) Anemia Depression HIV Infection/Disease Pneumothorax Anxiety Diabetes Kidney Stones/Disease Seizure Disorder Anorexia/Bulimia Dizziness/Fainting Spells Learning Disabilities Sickle Cell Anemia Arthritis Emotional/Mental Health Illness Meningitis Bacterial/Viral STD’s Asthma Frequent Ear Infections Menstrual Problems Substance Abuse Problems Bronchitis Heart Disease/Problems/Murmurs Migraines/Chronic Headaches Thyroid Disease Back Problems Hepatitis (Type: ) Mononucleosis TB/Tuberculosis Cancer Head Injury/Concussion Neuromuscular Disease Ulcer/Stomach Problems Chicken Pox High Blood Pressure Nose Bleeds UTI’s Frequent/Recurrent Crohn’s/Colitis/BS High Cholesterol Phlebitis/Deep Vein Blood Clot Vision/Hearing Problems OTHER: Please Explain Checked Answers:

ARE YOU CURRENTLY UNDER A PHYSICIAN’S CARE? IF YES PLEASE EXPLAIN. ARE YOU CURRENTLY, OR PREVIOUSLY BEEN, IN COUNSELING? IF YES PLEASE EXPLAIN. ARE YOU CURRENTLY TAKING MEDICATIONS? IF YES PLEASE LIST MEDICATIONS AND LIST PRESCRIBER(S). ANY PRIOR HOSPITALIZATIONS? IF YES PLEASE LIST DATES, DIAGNOSIS, AND SURGERIES.

ANY OTHER PRIOR ORTHOPAEDIC INJURIES?

ANY ALLERGIES? IF YES PLEASE LIST.

DO YOU HAVE AN EPI PEN? YES / NO IF YOU HAVE ASTHMA DO YOU HAVE AN INHALER? YES / NO IF AVAILABLE, WHAT IS YOUR BEST PEAK FLOW?

FAMILY HISTORY LIFESTYLE Has anyone in your immediate family 1. Alcohol (Drinks/day)? ______Yes No Relationship had any of the following? 2. Cigarettes/Vape per day? ______Years Smoked/Vaped? ______Alcoholism 3. Do you diet frequently? ______Asthma 4. Do you exercise regularly (days/week)? ______5. Do you or have you ever used recreational drugs? Bleeding Disorders Yes / No What type? ______Epilepsy/Seizures 6. Do you or have you ever used prescription medications for recreational use? Emotional Disorders Yes / No What type? ______Heart Attack Heart Disease

High Blood Pressure ALL INFORMATION PROVIDED IS CONFIDENTIAL Kidney Disease Stroke Breast Cancer PROGRAMS INTERESTED IN ATTENDING

Other Cancer 1. Exercise Classes (Circle all that apply) Other Yoga / Pilates / Step Classes / Muscle Mix / Kickboxing / Other______Depression/Anxiety/Panic Disorder 2. Stop smoking program? Yes / No 6. Nutrition Class? Yes / No Other 3. Substance abuse program? Yes / No 7. Heart Health Class? Yes / No

I have answered these questions to the best of my knowledge. 4. Stress reduction classes? Yes / No 8. Anger management? Yes / No 5. Weight loss program? Yes / No 9. Other ______STUDENT SIGNATURE X______

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PHYSICIAN PHYSICAL EXAM FORM Physician, please review the Student Health History and complete Physician Form, no attachments accepted. A physical exam within the calendar year is required. *FOR ATHLETIC, CLUB SPORT OR INTRAMURAL IT IS MANDATORY.*

STUDENT NAME: DATE OF BIRTH:

AGE SEX M F WEIGHT HEIGHT BMI B/P / T P R U/A S.G. PH PROTEIN SUGAR OTHER Hgb/Hct Cholesterol

MEDICAL EXAM NORMAL ABNORMAL MEDICAL EXAM NORMAL ABNORMAL COMMENT ON ABNORMAL FINDINGS Appearance Abd, Liver, Spleen, Kidneys Skin G-U System Eyes (lids, conjunctiva, pupils) Rectal Ears (canals, drums) Hernia Vascular (femoral, pedal pulses, Nose, Sinuses, Throat varicosities) Mouth, Teeth, Gingiva Lymph Nodes Neurological (gait, patellar, Neck, Thyroid Achilles reflexes, balance) Musculoskeletal (back, spine, Chest, Breasts joints, shoulders, knees, ankles) Lungs Heart NO YES CARDIAC SCREENING COMMENT ON YES ITEMS PHYSICAL EXAM Chest pain with exercise Normal Abnormal Precordial Auscultation Fainting or dizziness with exercise Supine Heart races or skips beat with exercise Squatting

Hypertension Standing Standing with Valsalva Family hx of sudden death before age 50 Femoral artery pulses Family hx heart disease before age 50 COMMENT ON ABNORMAL ITEMS Dilated cardiomyopathy Long Q-T syndrome Marfan’s Syndrome Clinically important arrhythmias Heart murmur

PHYSICAL STIGMATA FOR MARFAN SYNDROME  YES  NO *CLEARED TO PARTICIPATE IN INTERCOLLEGIATE SPORTS?*  YES  NO PLEASE INDICATE RESTRICTIONS HERE ANY PRIOR RESTRICTION IN THE PAST?  YES  NO ANY PRIOR CARDIOLOGY TESTING?  YES  NO LIST CURRENT MEDICATIONS (Include vitamins, OTC’s, contraceptives) LIST ANY PHYSICAL, PSYCHOLOGICAL OR LEARNING DISABILITIES

LIST ALLERGIES (Include medications, foods, insect venoms) LIST SPECIAL DIETARY REQUIREMENTS Type of reaction/Exposure Treatment.

See immunization form - must be signed by MD, NP or PA. IMMUNIZATIONS ARE UP TO DATE ACCORDING TO GUIDELINES?  YES  NO See Tuberculosis Risk Questionnaire and Medical Evaluation for Latent Tuberculosis Infections. Student is:  LOW RISK for TB  HIGH RISK for TB HIGH RISK: If the answer to questions 2, 3 OR 4 is YES, Nichols College requires that you have a tuberculin skin test (Mantoux test/Intermediate PPD) to check for latent tuberculosis infection. LOW RISK: If the answer to all of the questions is NO, a tuberculin skin test is NOT needed.

Office Stamp

PHYSICIAN SIGNATURE PRINT PHYSICIAN NAME

DATE OF EXAM ADDRESS

PHONE NUMBER FAX NUMBER

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IMMUNIZATION RECORD FORM Please review with your Physician at time of exam, physician signature required. College Immunization Law, Chapter 76, Section 15c REQUIRES the following proof of immunizations FORM MUST BE COMPLETED. NO ATTACHMENTS ARE ACCEPTED, only lab reports.

STUDENT NAME: DATE OF BIRTH: M.I. Last DD/MM/YY

A. TETANUS-DIPHTHERIA (Td) or TDAP required within the last 5 years for Full Time Freshman

❑ 1 dose Tdap, then Td booster every 10 years / / Tdap - / / B. M.M.R. (MEASLES, MUMPS, RUBELLA) – 2 doses required

❑ Dose 1 on or after 1st birthday / / ❑ Dose 2 at least one month after dose 1 / / OR 1. MEASLES (Rubeola) – If given instead of MMR, 2 doses required. Initial vaccines must be after 1967

❑ Dose 1 on or after 1st birthday / / ❑ Dose 2 at least one month after dose 1 / / ❑ OR Positive Measles antibody titer (Attach lab report) / / 2. RUBELLA – If given instead of MMR, 2 doses required

❑ Dose 1 on or after 1st birthday / / ❑ Dose 2 at least one month after dose 1 / / ❑ OR Positive Rubella antibody titer (Attach lab report) / / 3. MUMPS – If given instead of MMR, 2 doses required

❑ Dose 1 on or after 1st birthday / / ❑ Dose 2 at least one month after dose 1 / / ❑ OR Positive Mumps antibody titer (Attach lab report) / / C. VARICELLA VACCINE – 2 doses required for Full Time Freshman. Must be given at least one month apart if immunized after age Dose 2 Date / / ❑ Dose 1 Date / / ❑ OR Immune Titer / / (Attach lab report) ❑ OR positive history of disease : Date / / D. HEPATITIS B VACCINE – 3 doses required Dose 2 Date / / Dose 3 Date / / ❑ Dose 1 Date / / ❑ OR Positive Hepatitis B surface antibody / / (Attach lab report) E. MENINGOCOCCAL VACCINE: ALL RESIDENTIAL STUDENTS REQUIRE MENINGITIS IMMUNIZATION. Waiver must be signed if nonresidential and opt not to receive.

❑ Dose Date / / TYPE: Medical Evaluation for Latent Tuberculosis Infections - See questionnaire in packet. The new meningococcal requirement is as follows: All newly enrolled full time students 21 years of age and younger must have received a dose of quadrivalent meningococcal vaccine (MenACWY) on or after the 16th birthday. Students may submit a medical or religious exemption to meningococcal vaccine, or sign the attached waiver indicating they reviewed the meningococcal information sheet and choose to waive receipt of meningococcal vaccine. The attached waiver form has been updated to reflect the new requirements and the latest recommendations on meningococcal vaccine. Please note that meningococcal B vaccine does not fulfill the meningococcal requirement.

HEALTHCARE PROVIDER SIGNATURE (Required) DATE (DD/MM/YYYY)

PRINT NAME OF EXAMINER MD, DO, NP, PA SIGNATURE OF EXAMINER (CIRCLE) DATE (DD/MM/YYYY)

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TUBERCULOSIS RISK QUESTIONNAIRE Must be completed by all students and returned with Health Record. Please bring this form to your physician physical exam.

STUDENT NAME: COUNTRY OF BIRTH: First M.I. Last

Have you ever had a positive tuberculosis skin test? (If yes, continue to next page)  YES  NO To the best of your knowledge, have you had close contact with anyone who was sick with tuberculosis (TB)?  YES  NO Were you born in one of the countries listed below?  YES  NO Have you traveled or lived for more than one month in any of the countries listed below?  YES  NO

COUNTRIES WITH HIGH RATES OF TUBERCULOSIS Afghanistan Colombia India Morocco Solomon Islands Angola Comoros Indonesia Mozambique Somalia Armenia Congo Iran Myanmar South Africa Azerbaijan Congo, DR Kazakhstan Namibia Sri Lanka Bahamas Cote d'Ivoire Kenya Nepal Sudan Bahrain Croatia Kiribati New Caledonia Suriname Bangladesh Djibouti Korea, DPR Nicaragua Swaziland Belarus Dominican Republic Korea, Rep. Niger Syrian Arab Republic Benin Ecuador Kyrgyzstan Nigeria Tajikistan Bhutan El Salvador Lao PDR Niue Tanzania, UR Bolivia Equatorial Guinea Latvia Northern Mariana Islands Thailand Bosnia & Herzegovina Eritrea Lesotho Pakistan Togo Botswana Estonia Liberia Palau Tokelau Brazil Ethiopia Lithuania Panama Turkmenistan Brunei Darussalam Gabon Macedonia, TFYR Papua New Guinea Uganda Burkina Faso Gambia Madagascar Paraguay Ukraine Burundi Georgia Malawi Peru Uzbekistan Cambodia Ghana Malaysia Maldives Philippines Vanuatu Cameroon Guam Mali Portugal Viet Nam Cape Verde Guatemala Marshall Islands Romania Yemen Central African Republic Guinea Mauritania Russian Federation Zambia Chad Guinea-Bissau Mauritius Rwanda Zimbabwe China Guyana Micronesia Sao Tome & Principe China, Hong Kong SAR Haiti Moldova, Rep. Senegal China, Macao SAR Honduras Mongolia Sierra Leone

HIGH RISK If your answer to questions 2, 3 OR 4 is YES, Nichols College requires that you have a tuberculin skin test (Mantoux test/ lntermediate PPD) to check for latent tuberculosis infection. Your healthcare provider must complete the form on the following page.

LOW RISK If the answer to ALL of the above questions is NO, a tuberculin skin test should not be done. Please disregard the following page of this form.

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Medical Evaluation for Latent Tuberculosis Infection TO BE COMPLETED AND SIGNED BY A LICENSED HEALTHCARE PROVIDER

STUDENT NAME: DATE: First M.I. Last (DD/MM/YYY)

PLEASE NOTE: If patient has had a positive tuberculin skin test in the past, the test should not be repeated - proceed to Section B below.

A. TUBERCULIN SKIN TEST (Mantoux/lntermediate PPD) Test must be read by a healthcare provider 48-72 hours after administration. If no induration, mark "0". Result of multiple puncture tests, such as Tine or Mono-Vac, are NOT accepted.

/ / / / mm of induration Date test administered (DD/MM/YYYY) Date test read (DD/MM/YYYY) Result

INTERPRETATION OF TUBERCULIN SKIN TEST: (Please use table below)  NEGATIVE  POSITIVE

RISK FACTOR POSITIVE RESULT Close contact with a case of tuberculosis 5 mm or more Born in a country that has a high rate of tuberculosis 10 mm or more Traveled or lived for a month or more a country that has a high rate of tuberculosis 10 mm or more No risk factors (test not recommended) 15 mm or more

B. If Tuberculin Skin Test is POSITIVE, now or by history, the following are required:

1. Date of positive PPD: / / Date of Positive PPD (DD/MM/YYYY)

2. Chest X-ray (required) Attach report, NOT the x-ray / /  NORMAL  ABNORMAL: Date of X-ray (DD/MM/YYYY) (Please describe)

3. Clinical Evaluation  NORMAL  ABNORMAL: (Please describe)

4. Treatment  NO  YES: (Drug, dose, frequency, and dates)

HEALTHCARE PROVIDER SIGNATURE (require d)

(DD/MM/YYYY) PHONE FAX

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Information about Meningococcal Disease, Meningococcal Vaccines, Vaccination Requirements and the Waiver for Students at Colleges and Residential Schools

Colleges: Massachusetts requires all newly enrolled full-time students 21 years of age and under attending a postsecondary institution (e.g., colleges) to: receive a dose of quadrivalent meningococcal conjugate vaccine on or after their 16th birthday to protect against serotypes A, C, W and Y or fall within one of the exemptions in the law, discussed on the reverse side of this sheet.

Residential Schools: Massachusetts requires all newly enrolled full-time students attending a secondary school who will be living in a dormitory or other congregate housing licensed or approved by the secondary school or institution (e.g., boarding schools) to receive a dose of quadrivalent meningococcal conjugate vaccine to protect against serotypes A, C, W and Y or fall within one of the exemptions in the law, discussed on the reverse side of this sheet.

The law provides an exemption for students signing a waiver that reviews the dangers of meningococcal disease and indicates that the vaccination has been declined. To qualify for this exemption, you are required to review the information below and sign the waiver at the end of this document. Please note, if a student is under 18 years of age, a parent or legal guardian must be given a copy of this document and must sign the waiver.

What is meningococcal disease? Meningococcal disease is caused by infection with bacteria called Neisseria meningitidis. These bacteria can infect the tissue that surrounds the brain and spinal cord called the “meninges” and cause meningitis, or they can infect the blood or other body organs. Symptoms of meningitis may appear suddenly. Fever, severe and constant headache, stiff neck or neck pain, nausea and vomiting, and rash can all be signs of meningitis. Changes in behavior such as confusion, sleepiness, and trouble waking up can also be important symptoms. In the US, about 1,000-1,200 people get meningococcal disease each year and 10-15% die despite receiving antibiotic treatment. Of those who live, another 11-19% lose their arms or legs, become hard of hearing or deaf, have problems with their nervous systems, including long term neurologic problems, or suffer seizures or strokes.

How is meningococcal disease spread? These bacteria are passed from person-to-person through saliva (spit). You must be in close contact with an infected person’s saliva in order for the bacteria to spread. Close contact includes activities such as kissing, sharing water bottles, sharing eating/drinking utensils or sharing cigarettes with someone who is infected; or being within 3-6 feet of someone who is infected and is coughing or sneezing.

Who is at most risk for getting meningococcal disease? High-risk groups include anyone with a damaged spleen or whose spleen has been removed, those with persistent complement component deficiency (an inherited immune disorder), HIV infection, those traveling to countries where meningococcal disease is very common, microbiologists who work with the organism and people who may have been exposed to meningococcal disease during an outbreak. People who live in certain settings such as college freshmen living in dormitories and military recruits are also at greater risk of disease from some of the serogroups.

Are some students in college and secondary schools at risk for meningococcal disease? College freshmen living in residence halls or dormitories are at an increased risk for meningococcal disease caused by some of the serotypes contained in the quadrivalent vaccine, as compared to individuals of the same age not attending college. The setting, combined with risk behaviors (such as alcohol consumption, exposure to cigarette smoke, sharing food or beverages, and activities involving the exchange of saliva), may be what puts college students at a greater risk for infection. There is insufficient information about whether new students in other congregate living situations (e.g., residential schools) may also be at increased risk for meningococcal disease. But, the similarity in their environments and some behaviors may increase their risk.

The risk of meningococcal disease for other college students, in particular older students and students who do not live in congregate housing, is not increased. However, quadrivalent meningococcal vaccine is a safe and effective way to reduce their risk of contracting this disease. In general, the risk of invasive meningococcal B disease is not increased among college students relative to others of the same age not attending college. However, outbreaks of meningococcal B disease do occur, though rarely, at colleges and universities. Vaccination of students with meningococcal B vaccine may be recommended during outbreaks. Provided by: Massachusetts Department of Public Health / Division of Epidemiology and Immunization / 617-983-6800 MDPH Meningococcal Information and Waiver Form Updated January 2018

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Provided by: Massachusetts Department of Public Health / Division of Epidemiology and Immunization / 617-983-6800 MDPH Meningococcal Information and Waiver Form Updated January 2018 Is there a vaccine against meningococcal disease? Yes, there are 2 different meningococcal vaccines. Quadrivalent meningococcal conjugate vaccine (Menactra and Menveo) protects against 4 serotypes (A, C, W and Y) of meningococcal disease. Meningococcal serogroup B vaccine (Bexsero and Trumenba) protects against serogroup B meningococcal disease. Meningococcal conjugate vaccine is routinely recommended at age 11-12 years with a booster at age 16. Students receiving their first dose on or after their 16th birthday do not need a booster. Individuals in certain high risk groups may need to receive 1 or more of these vaccines based on their doctor’s recommendations. Adolescents and young adults (16-23 years of age) who are not in high risk groups may be vaccinated with meningococcal B vaccine, preferably at 16-18 years of age, to provide short-term protection for most strains of serogroup B meningococcal disease. Talk with your doctor about which vaccines you should receive.

Is the meningococcal vaccine safe? Yes. Getting meningococcal vaccine is much safer than getting the disease. Some people who get meningococcal vaccine have mild side effects, such as redness or pain where the shot was given. These symptoms usually last for 1-2 days. A small percentage of people who receive the vaccine develop a fever. The vaccine can be given to pregnant women. A vaccine, like any medicine, is capable of causing serious problems such as severe allergic reactions, but these are rare.

Is meningococcal vaccine mandatory for entry into secondary schools that provide housing, and colleges? Massachusetts law (MGL Ch. 76, s.15D) and regulations (105 CMR 220.000) requires both newly enrolled full-time students attending a secondary school (those schools with grades 9-12) who will be living in a dormitory or other congregate housing licensed or approved by the secondary school or institution and newly enrolled full-time students 21 years of age and younger attending a postsecondary institution (e.g., colleges) to receive a dose of quadrivalent meningococcal vaccine.

At affected secondary schools, the requirements apply to all new full-time residential students, regardless of grade (including grades pre-K through 8) and year of study. Secondary school students must provide documentation of having received a dose of quadrivalent meningococcal conjugate vaccine at any time in the past, unless they qualify for one of the exemptions allowed by the law. College students 21 years of age and younger must provide documentation of having received a dose of quadrivalent meningococcal conjugate vaccine on or after their 16th birthday, unless they qualify for one of the exemptions allowed by the law. Meningococcal B vaccines are not required and do not fulfill the requirement for receipt of meningococcal vaccine. Whenever possible, immunizations should be obtained prior to enrollment or registration. However, students may be enrolled or registered provided that the required immunizations are obtained within 30 days of registration.

Exemptions: Students may begin classes without a certificate of immunization against meningococcal disease if: 1) the student has a letter from a physician stating that there is a medical reason why he/she can’t receive the vaccine; 2) the student (or the student’s parent or legal guardian, if the student is a minor) presents a statement in writing that such vaccination is against his/her sincere religious belief; or 3) the student (or the student’s parent or legal guardian, if the student is a minor) signs the waiver below stating that the student has received information about the dangers of meningococcal disease, reviewed the information provided and elected to decline the vaccine.

Where can a student get vaccinated? Students and their parents should contact their healthcare provider and make an appointment to discuss meningococcal disease, the benefits and risks of vaccination, and the availability of these vaccines. Schools and college health services are not required to provide you with this vaccine.

Where can I get more information? • Your healthcare provider • The Massachusetts Department of Public Health, Division of Epidemiology and Immunization at (617) 983-6800 or www.mass.gov/dph/imm and www.mass.gov/dph/epi • Your local health department (listed in the phone book under government)

Waiver for Meningococcal Vaccination Requirement I have received and reviewed the information provided on the risks of meningococcal disease and the risks and benefits of quadrivalent meningococcal vaccine. I understand that Massachusetts’ law requires newly enrolled full- time students at secondary schools who are living in a dormitory or congregate living arrangement licensed or approved by the secondary school, and newly enrolled full-time students at colleges and universities who are 21 years of age or younger to receive meningococcal vaccinations, unless the students provide a signed waiver of the vaccination or otherwise qualify for one of the exemptions specified in the law. ❑ After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of meningococcal vaccine.

Student Name:______Date of Birth:______Student ID:______

Signature: ______Date: ______(Student or parent/legal guardian, if student is under 18 years of age)

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NICHOLS COLLEGE Department of Sports Medicine (Front) Waiver Form 2020-2021

Name: ______Sport(s): ______

ACCEPTANCE OF RISK

I understand that participation in intercollegiate athletics includes the risk of injury, including, but not limited to, serious permanent injury and death. I further understand that such injuries may occur in the absence of negligence.

To minimize the risk of injury, I agree to obey all safety rules, to report fully any problems related to my physical condition to the appropriate college personnel, including the Sports Medicine staff and coaches at Nichols College, to follow prescribed conditioning programs, and to inspect my athletic equipment daily for defects.

I acknowledge that I am fully aware of the risk of injury inherent in athletic activities and that such risks may include death, serious permanent bodily injury, and/or impairment of my future capacities to earn a living, to engage in other business, social, and recreational activities. I acknowledge that I am participating in these activities voluntarily. I understand my obligations, as set forth in this document, and agree to meet these obligations as a condition of my participation.

Initial ______

RELEASE REGARDING BODY PIERCING AND JEWELRY

As a Nichols College student-athlete, I hereby agree not to file claims or lawsuits against Nichols College, Department of Athletics on account of injuries to myself or other that were caused by or made more serious by my body piercing(s) and/or body piercing jewelry. I agree to take full responsibility for my body piercing(s) and all body piercing jewelry that I wear, and I also take full responsibility for any injuries or other problems that might occur to me or others as a result of them. I acknowledge that the Sports Medicine staff of the Department of Athletics strongly recommends that I remove all body piercing jewelry during every practice and every competition whether or not team rules require it. Initial ______

ACCEPTANCE OF CONCUSSION MANAGEMENT

I understand that it is my sole responsibility to report any injuries and illnesses which I may endure during intercollegiate participation, including any signs and symptoms related to concussion or head injury, in a prompt and timely fashion to the Nichols College Sports Medicine staff.

I acknowledge my full responsibility for my reporting and I agree to comply with the NCAA Concussion Management Plan as it states, “a student-athlete who exhibits signs, symptoms, or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by an athletics healthcare provider.” In addition, I acknowledge that any “student-athlete diagnosed with a concussion shall NOT return to activity for the remainder of the day,” and that medical clearance shall be determined by the team physician or the Nichols College Sports Medicine staff. Initial ______

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NICHOLS COLLEGE Department of Sports Medicine (Back) Waiver Form 2020-2021

EQUIPMENT CONSENT

The following is to be read and completed only if the sport is football, , , baseball, softball, or lacrosse:

“NO HELMET CAN PREVENT ALL HEAD OR NECK INJURIES A PLAYER MIGHT RECEIVE WHILE PARTICIPATING IN FOOTBALL, ICE HOCKEY, FIELD HOCKEY, BASEBALL, SOFTBALL, OR LACROSSE.”

“DO NOT USE YOUR HELMET TO BUTT, RAM, OR SPEAR AN OPPOSING PLAYER. THIS IS A VIOLATION OF THE RULES AND SUCH USE CAN RESULT IN SEVERE HEAD OR NECK INJURIES, PARALYSIS OR DEATH TO YOU AND POSSIBLE INJURY TO YOUR OPPONENT.”

The above warning statement is located on the helmet that Nichols College provides for participation in football/ice hockey/field hockey/baseball/softball/lacrosse.

The Nichols College Sports Medicine staff strongly discourages the wearing of bandanas, “du-rags”, stocking caps, etc. Anything worn under the helmet may adversely affect the fit, effectiveness and protective ability of the helmet. To wear the aforementioned items is done at your own risk.

Initial ______

INSURANCE CONSENT

I do hereby certify that the insurance information is complete and accurate. I also understand that the above insurance is to be utilized for medical expenses incurred during my participation in the College’s intercollegiate athletic program. I authorize Nichols College and/or its insurance agent to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays and any other data covering any previous confinements and/or disabilities. A photocopy of this authorization shall be deemed as effective and valid as the original. I have read, understand, and accept the Nichols College Athletic Injury Insurance Policy. I also consent to the College or it’s insurance agent to pay the medical vendors direct for any bills incurred from accidents that are covered under the College’s athletic injury insurance.

Initial ______

By initialing ALL sections above, and signing below, I acknowledge that I have read and understand the Nichols College Sports Medicine waiver form to its entirety and that I have read and understand the above warning statements.

______Signature of Student-Athlete Date

______Parent/Guardian Signature Date (If under age 18)

Nichols College Department of Sports Medicine 114 Center Rd, Dudley, MA 01571 Phone (508) 213-2183 Fax (508) 213-2446

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Sickle Cell Testing Waiver Form

1. By signing this waiver, my parent/guardian and I, both certify we understand that the NCAA Division III and Nichols College requires all incoming and returning student athletes to undergo testing for sickle cell trait. Furthermore, we have read and fully comprehend the information provided regarding sickle cell trait.

2. By providing our signatures below, I confirm that I do not wish to undergo testing for sickle cell trait. In consideration of this waiver, I hereby RELEASE, WAIVE, HOLD, HARMLESS, INDEMNIFY, DISCHARGE, AND CONVENANT NOT TO SUE the College, its Trustees, officers, agent, or employees from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action, whatsoever that may arise from my (or my minor child’s) decision to forego sickle cell trait testing for their participation in a tryout or any other physical activity on campus with the intercollegiate sports program.

3. In signing this Sickle Cell Trait Testing Wavier Form, I acknowledge and represent that I have read the entirety of the NCAA Sickle Cell Trait Information Fact Sheet and Waiver Form, that I understand it and sign in voluntarily, and that no oral representations, statements, or inducements, apart from the foregoing written document have been made to me on the subject matter of this document which have otherwise caused me to sign this waiver form, that I am fully competent, and that I execute this Waiver for full, adequate, and complete consideration fully intending for me (and my minor child) to be bound by the same.

4. In signing this Sickle Cell Trait Testing Wavier Form, I also acknowledge that I will be required to sit through an educational component with the sports medicine staff to ensure that I understand what risks I am taking by not being tested.

I further certify that (Check One):

I am at least eighteen (18) years of age and fully competent; or that I am

Under eighteen (18) years of age, and my parent or guardian is also signing individually and on my behalf and we both agree to bind by the terms of this Sickle Cell Trait Testing Waiver Form.

Student Name (Please Print) Date of Birth

Student’s Signature Date

Parent/Guardian Name (Please Print) Parent/Guardian Signature Date

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