Emergency Medical Consent

STUDENT NAME: DOB: PARENT NAME:

EMERGENCY MEDICAL CONSENT

I hereby CONSENT that Chileda may provide my child routine medical care (including vaccinations) and dental care as well as emergency medical care, dental care, and surgical care recommended by a qualified physician.

Student Signature (if 14 or over) Date Parent/Guardian Signature Date

Chileda agrees:

1. To notify the said parent or guardian of any serious illness, special treatment, or hospitalization needed by, and recommended for, the child by a physician or surgeon licensed to practice medicine and surgery, and also of special dental treatment.

2. To obtain consent of the parent or guardian for any surgery recommended by a surgeon, except in the case of emergency surgery.

3. In the event of the need for emergency surgery, to exert reasonable effort compatible with the nature and time limitation of the emergency, to secure the consent of the said parent or guardian. When this is not possible, Chileda Institute, Inc. will make effort to notify the parent as soon as possible after the surgery, of its occurrence, and the circumstances.

4. To obtain parental or guardian consent prior to making modifications to said child’s psychotropic medications, unless the situation is deemed medically necessary due to an emergency situation, is ordered by a licensed physician, or Chileda Institute, Inc. is unable to contact the parent or guardian.

Health and Wellness Care Coordinator Date

Effective January 2017 Day School Consent Forms Page 1of 23 STUDENT NAME: DOB: PARENT NAME:

OFF-CAMPUS MEDICATION FOR STUDENTS WITH SEIZURE DISORDERS

For children without seizure disorders:

My child is not prescribed seizure medications.

Parent/Guardian Signature Date

For children with seizure disorders:

Scheduled (PRN) seizure medication is not sent on recreational or classroom outings within 20 miles of the Chileda campus. 911 will be called if needed.

If my child is prescribed PRN medications for seizures, I grant permission fora Chileda staff member trained in medication administration to administer this medication as per the seizure protocol

Ordering Physician Date

DAY SCHOOL PROGRAM MEDICATION PROCEDURES CONSENT FORM Click here to enter text.SCHOOL YEAR FOR: Click here to enter text.(Student’s name)

All parents and/or guardians are required to sign a Chileda Day Program Medication Procedures Consent Form prior to placement with Chileda’s day school programing program.

If your child is in need of medication distribution for the administration of your child’s medications, please have your child’s physician sign a School Medication Procedure Form (available at your doctor’s office) for any prescribed medications dispensed while at Chileda. If a medication is sent to school for your child without an order from his/her physician, Chileda’s Health and Wellness Department will not administer it to your child.

All prescribed medications brought to Chileda shall be given to Chileda’s Health and Wellness Department in originally labeled containers dispensed from your child’s pharmacy (fixed with pharmacy label). These labels must coincide with the exact order written by the physician. If the labels on the containers do not coincide with the exact orders written by the physician, Chileda will not dispense them to your child.

If your pharmacy is able to package your child’s medications in a bubble or blister pack, this packaging is preferred.

Chileda has the ability to dispense some over the counter medications to your child while they are in school at Chileda (acetaminophen, cough drops, anti-acids). These medications can be provided by Chileda on an as-needed basis or you can bring them specifically to be used for your child. If they are brought from home, they must come in original bottles with original labels.

Any over-the-counter medications you wish to have Chileda dispense for your child will need to have a physician’s order. Please have you child’s physician fill out the As Needed Medication School Medication Form for your child.

Medications administered at Chileda will be dispensed by a Wisconsin (CBRF) Certified Medical Facilitator.

I understand the above information regarding Chileda’s Medication Procedures for day school programming and agree to adhere to its policies.

AS NEEDED MEDICATION DAY SCHOOL MEDICATION FORM

Chileda has permission to dispense the following over the counter medications to: Click here to enter text. (student’s name) while she/he is in programming at Chileda’s day school program (please check all that can apply).

 Acetaminophen liquid  2 tsp.  2 1/2tsp. May be repeated every 4 hours as needed for pain/fever,  3 tsp. not more than 5 times per day.

 Acetaminophen Jr.  2 tabs  4tabs  May be repeated every 4 hours as needed for pain/fever, not more than 5 times per day. Chewable tablets 2 1/2tabs  3 tabs  3 1/2 tabs

 Acetaminophen  325 mg May be repeated every 4 hours as needed for pain/fever,  650 mg not more than 5 times per day.  NO Acetaminophen

 Liquid Anti-acid  2 tsp. (10ml) Can give to coat stomach/settle stomach or for  4tsp. (20ml) Gas/Belching/Heartburn. Can give every hour as needed.

 Anti-acid tablets  2 tabs (Gas/Belching/Heartburn) Chew 1 to 2 tablets; repeat hourly as symptoms occur as needed.

 NO Liquid Anti-acid  NO Anti-acid tablets  Cough drops  1 drop May give one drop every hour for cough, sore throat as needed.  NO Cough drops

Parent/Guardian Name

Doctor’s Name

Doctor’s Signature Date

DAY SCHOOL ILLNESS, ABSENTEEISM AND EMERGENCY MEDICAL POLICY

Please read the following policy and procedure regarding student illness, absenteeism and emergency medical care. Please provide a signature indicating you have read the information and agree to adhere to the policies.

 My child will not be allowed to come to Chileda is exhibiting signs of illness or symptoms of illness directly prior to coming to Chileda

 My child will not be allowed to come to Chileda if exhibiting a fever of 101.0 or higher, is vomiting, or has diarrhea, directly prior to coming to Chileda.

 My child will not be allowed to come to Chileda if he/she is suffering from any communicable disease such as strep throat, whooping cough, influenza, chicken pox, lice, scabies, etc., until a physician’s statement is generated indicating that the student is no longer contagious or at risk of spreading the particular communicable disease.

 If my child becomes ill while at Chileda, I will be notified and agree to make immediate arrangements to pick up my child from Chileda.

 In the event that my child needs emergency care, I understand that Chileda will call 911 and have my child transported to the nearest medical facility to see a physician via ambulance. I understand I will be contacted as soon as possible once 911 is contacted.

 I accept financial responsibility for any emergency medical care that is provided to my child while he/she is at Chileda.

 In non-emergency situations that require a physicians’ care, I will be notified and will be advised to have my child see a physician. I will be responsible for providing transportation for my child to see a physician in a non-emergency situation.

 I will ensure that written documentation is provided to Chileda by my child’s physician indicating that my child is not at risk to self of others if he/she has required care by a physician for illness or injury.

 I will provide Chileda advanced notice regarding any planned absences not the result of the school calendar days off. I will provide Chileda notice as soon as possible if my child is not in attendance due to illness of other unplanned absences.

Number I can be reached:

Emergency contact & number if I cannot be reached:

Emergency contact relationship to the child:

CHILEDA PARENT COMMUNICATION FORM

Communication with teacher:

Preferred method of contact:

Phone: (number)

E-mail (address)

Letter (address)

Preferred frequency of contact:

2 x per week 1 x per week

Every other week

Days and times (between 7:30am-4pm) that you are available to communicate with the teacher:

Monday Tuesday Wednesday

Thursday Friday

Comments/Notes:

Number I can be reached: Emergency contact & number if I cannot be reached: Emergency contact relationship to the child:

PERSONAL PROPERTY AND ELECTRONICS POLICY

Chileda provides an array of both technological and traditional recreational and educational items for students who live and learn at our facility. Students have scheduled access to electronic devices including cd players, radios, computers, tablets, and video games.

Prohibited items include, but are not limited to:  Any items containing or made of glass; mirrors, glass in frames  Any weapons – real or toy, including pictures of weapons.  Any materials with adult or “mature” content including but not limited to movies, games, posters, magazines  Any device with Wi-Fi capabilities  Any device with voice or picture recording capabilities  Personal computers and tablets  Personal televisions  Personal gaming systems  MP3 Players & I-Pods  Any other item listed in the Prohibited Personal Property Policy

If your child requires an electronic device for communication, Chileda may approve these supports on an individual basis if written into the student’s IEP. These electronic devices will only be used for communication purposes. Chileda will not be responsible for repairing or replacing any personal property or electronic devices that go missing or are damaged or destroyed by your child or in any circumstance during your child’s enrollment.

If unapproved personal property or electronic devices are sent to Chileda with your child, it will be mailed or sent home with you on your next visit. Any approved personal property sent to Chileda, it is done at your own risk and Chileda cannot guarantee it will return in the same condition. We recommend not bringing any item of personal or significant sentimental value or value over $50.

Chileda provides all bedding and towels. Students are allowed to bring one throw blanket and one washable 15” or smaller stuffed animal that is able to be washed in a traditional washing machine. Chileda also supplies engaging leisure activities therefore all personal items should be limited to fitting in two provided bins. Excess items will be sent home.

I acknowledge that Chileda is not responsible for the costs of personal property. I have read the statement above and understand sending items listed in the Prohibited Personal Policy will be returned promptly.

I further acknowledge that any purchased personal property will be done so at my own risk. I understand that the cost of repairing or replacing personal property during my child’s enrollment at Chileda is my parental/guardianship responsibility. I understand that Chileda is not financially responsible for any items that go missing, damaged, or destroyed for any reason during my child’s stay.

Student Signature Date

PERSONAL PROPERTY AND ELECTRONICS POLICY

Chileda does not allow the following personal items:

 Any items containing or made of glass; mirrors, glass frames

 Aerosol sprays

 Any electronics that have cameras, picture, video, or voice recording capabilities.

 Personal computers or laptops (pre-arranged use of iPads for communication purposes only will be approved on an individual basis)

 Personal TVs

 Tobacco products, matches or lighters

 Hair color/dye, chemical hair relaxers or perms

 Permanent markers or scissors

 Any toy weapons, real or toy knives or guns (including squirt guns)

 Any hand tools including saws, utility knives, screwdrivers, hammers, wrenches, etc.

 Music with a paternal advisory or “edited” music with inappropriate content

 Movies, video games, books, magazines or posters that display violence and/or sexual situations. “PG13”, “R” and unrated movies/games are not permitted.

 Curling irons or clothing irons

 Steel toes shoes or boots or dress shoes over an inch tall

 Clothing with inappropriate designs or logos representing alcohol or tobacco products

 Gang related clothing or items

 Christmas lights or extension cords

 Personal bikes, rollerblades, shoes with wheels or scooters

 Candles, plug-in air fresheners

 Disposable razors

Please see Personal Property and Electronics Policy for more information. Chileda will provide appropriate games, music, and grooming supplies for residents. The above list of prohibited items is not an all-inclusive list. If an item is questionable, the item will be kept until approval from a Case Coordinator or Manager is given.

*If you are unsure, please hold the item for a Case Coordinator or Manager to approve.

VERIFICATION OF RECEIVING STATEMENT OF RESIDENTS’ RIGHTS

With signature, I verify that I have received a written copy of the Statement of Residents’ Rights. Your son/daughter will review residents’ rights upon enrollment. The Statement of Residents’ Rights will be read and reviewed with my child in an effort to assist in the understanding and implementation of residents’ rights.

Further questions regarding my child’s rights can be directed toward the School Counselor and/or the Family Services Specialist.

BEHAVIORAL SUPPORT CONSENT FORM

A Functional Behavior Assessment (FBA) will be completed within my child’s first 30 days of placement and as needed thereafter. The FBA may include interviews with those who know your child well, direct observation, review of records and data, checklists, or adaptive behavior assessments. The FBA will be will be used to develop an appropriate Positive Behavior Support Plan (PBSP).

It is best practice to gain consent in the form of a signature from parents/guardians prior to the implementation of new behavioral interventions in the PBSP. The behavior department will make three attempts via e-mail, mail, or in person to gain consent prior to implementation of a program. Due to the distance between families and Chileda a phone approval will be accepted for implementation, however a signature will continue to be sought. At times a behavior intervention may need to be implemented immediately due to the severity of the behaviors. During these times a phone call will be made to parents/guardians to gain consent. If the parents/guardians are not able to be reached the program will be implemented while still attempting to gain consent. Behavior programs will be reviewed quarterly at the child’s treatment plan meeting.

The use of restrictive measures including forward escorts, restraint, and seclusionary time-outs are used as a last resort when imminent danger is present. It is standard practice to notify parents/guardians of the use of restrictive measures within 24 hours. Parents will work out a plan with the child’s Case Coordinator and indicate how frequently they will be notified of restrictive measures.

I have received a copy of the Behavior Services Departmental Policies and Procedures and I am aware that an oral discussion of this material is available upon my request. I may discuss or raise questions regarding these policies and procedures by contacting the Lead Behavior Specialist. I understand that consent is voluntary and may be revoked at any time by notifying Chileda Institute, Inc. in writing.

I give my consent for my child to participate in behavioral approaches as outlined in the Behavior Services Departmental Policies and Procedures (excluding use of psychotropic medications) including behavior assessments and the use of restrictive measures including forward escorts, restraint, and seclusionary time-outs.

Behavior Services Date

PARENTAL CONSENT FORM Medication I consent to Chileda staff administering my child’s nonemergency and psychotropic medications including over the counter medications listed by the physician. Medication will be supplied in original, properly labeled containers. I will notify Chileda in writing with any changes in medications or with changes in my child’s medical condition. I will obtain updated physician orders for any changes that occur. I authorize Chileda’s medical personnel to contact my child’s physician if needed. I release Chileda of any liability claims as a result of the administration of medication or procedures as directed.

Student Signature (If over 14) Date

Program I hereby state that I am aware of and accept the risk inherent to my child participating in programming with other children and young adults who demonstrate severe behavior, including aggression and other explosive behaviors. The undersigned does hereby agree to hold harmless and indemnify the Chileda Institute, the Board, and employees from any and all liability, loss, damages, costs or expenses which are sustained, incurred or required arising out of my child’s participation in Chileda programming.

Field Trips and Transportation I give permission for my child to participate in walks, community activities, sports, field trips, swimming, roller skating, biking, and other school activities related to educational and recreational curriculums and treatment plans. I also give permission for Chileda to transport my child to these events in Chileda vehicles or transportation purchased or contracted by Chileda.

Classroom Moves Your child may move from one classroom to another. Moves are motivated by many factors including student’s progress, age, behavior supports needs, and new enrollments. Changes in classrooms are accompanied by structured events and other activities to ensure smooth and positive transitions for the students.

I acknowledge that my child may move from his or her classroom to another as deemed appropriate by Chileda staff. I will be informed of all moves.

VISITING YOUR CHILD AT CHILEDA

At Chileda, because we are primarily a residential facility, we must protect other student’s rights to privacy. We do not allow parents to be on Chileda’s campus other than designated areas when other students are present.

Confidentiality: For the safety and protection of your child and all students who live and learn at Chileda, HIPAA (Health Insurance Portability and Accountability Act) as well as safety measures and internal protocols are followed. Chileda is mandated to follow HIPAA, as we must preserve the privacy and guard the confidentiality of health and other confidential information for all students. Every individual receiving service at Chileda expects that confidentiality of information is maintained.

Planning your visit:  Please arrange a visitation plan and schedule with your child’s Teacher. Providing advanced notice allows us to prepare your child and to develop support strategies to make your visit positive.  Chileda will work with families on an individual basis to facilitate meaningful and enjoyable visits. o Please communicate with your child’s teacher to discuss needed supports (such as a calendar, social story, and/or visual schedule) for on campus visits.  Chileda requires that all visitors read and sign our “Confidentiality” statement in our visitor register. You will be asked to sign a confidentiality form at the time of your child’s enrollment. All visitors who come beyond the reception area will be asked to sign a confidentiality agreement at the time of each visit.  The front door is the only access into the campus for visitors. Once you sign in, the supervisor will accompany you to your child, or staff will be notified to accompany your child to the reception area.  To maintain confidentiality of all residents and staff at Chileda, we rely heavily on our visitor’s integrity. If at any point Chileda staff feel a visitor is violating confidentiality or disrupting programming, Chileda will restrict visits to assigned areas of campus or implement other interventions necessary to maintain confidentiality and privacy.  Photographs, videos and other recordings are not allowed.

PHOTO RELEASE FOR EDUCATION & TREATMENT SPECIFIC TO MY CHILD

I give permission for my child to be photographed for the purposes of education and treatment by Chileda Institute, Inc. (“Chileda”). Uses of these photographs will comply with his/her resident and/or student rights. This permission, for photographs used for the purpose of education and treatment of my child, will be requested annually. Parents may revoke this permission with written notice to Chileda at any time.

Please initial one (1) of the following:

Permission is granted.

Permission is not granted.

Photo and Video Release for Special Chileda Projects

I give permission for photographs of my child to be used to train staff and present Chileda to the public in the specific areas initialed below. If left blank, my child’s photograph may not be used in that area. Examples of how photographs may be used include posters, brochures, annual reports, website and conference presentations.

Please initial all areas in which photographs/ video of your child may be used:

Chileda’s campus, including the classroom or in the house

Conferences and other community opportunities

Chileda’s website

Chileda’s Facebook page and other social media

I hereby waive any right I/we may have to inspect and approve the finished products or the use to which it may be applied for educational or treatment purposes.

Permission granted for up to one (1) year of today’s date unless I indicate otherwise.

SOUND RECORDING RELEASE FOR MUSIC THERAPY & TREATMENT SPECIFIC TO MY CHILD

During the course of music therapy sessions there may be the opportunity for an individual child to make sound recordings of original songs or improvisations for use toward the child’s individualized music therapy goals. The music therapist will provide the sound recording device owned by Chileda Institute, Inc. (“Chileda”) and will monitor the content recorded. The recording device will be used only in the course of treatment of the music therapy session.

I give permission for my child to be sound recorded for the purposes of music therapy and treatment by Chileda. Uses of these recordings will comply with his/her resident and/or student rights. This permission, for recordings used for the purpose of music therapy and treatment of my child, will be requested annually. Parents may revoke this permission with written notice to Chileda at any time.

Please check one (1) of the following:

Permission is granted.

Permission is not granted.

Please check all areas in which sound recordings of your child may be used:

Given to child in the form of CD or on child’s personal mp3 player

Chileda’s campus

Conferences and other community opportunities

Chileda’s website

Chileda’s Facebook page and other social media

I hereby waive any right I/we may have to inspect and approve the finished products or the use to which it may be applied for music therapy or treatment purposes.

Permission granted for up to one (1) year of today’s date unless I indicate otherwise.

ART WORK RELEASE CONSENT FORM

Chileda is a member of Artsonia.com (www.artsonia.com), the largest online student art museum. Artsonia showcases artwork from thousands of schools around the world. Artsonia’s goals are to develop students’ pride and self esteem, increases their multicultural understanding through art and involve parents and relatives in student education and accomplishments. In accordance with our school policy, I am writing you to seek your permission for showcasing your child’s artwork on our school’s web gallery on Artsonia. The permission will cover their tenure at our school. Please read the note below, sign this form and return it to me so that I may publish your child’s artwork. This is a unique, safe, and exciting educational opportunity for the students. Let’s join the millions of other famous child artists on the internet! Comments on your child’s artwork: One of the most exciting features about being published on Artsonia’s Art Museum is that friends and family can leave a nice comment for the artist and become a fan club member of the artist. These comments are given to the student to feel proud of their artwork and the support they receive. As a security feature, Artsonia requires the parent to pre-approve all comments before they are posted on the website. This is one of the many examples of how important your child’s safety and privacy are to Artsonia.

Parental Permission Form: I give my permission to display my child’s artwork on Artsonia, in accordance with Artsonia’s terms and conditions of use ***. I understand that Artsonia preserves students’ privacy and anonymity by listing the artwork only under the student’s first name and a number- last names are never revealed. I also understand that Artsonia will only display comments on student artwork with parental permission, and therefore grant Artsonia permission to email notifications to me when new comments are available for review. NOTE: This permission will cover the entire tenure of my child at this school. *** Complete details on Artsonia’s terms and conditions can be found at www.artsonia.com/terms

Student’s name Student’s grade (optional)

Parent’s Name Relationship: Father Mother Guardian

Email address:

Email is required for parents to approve visitor comments. Artsonia does not share your email address with anyone. If you do not have an email address, you may have to leave this field blank, but your child’s artwork will not have comments displayed.

RELEASE OF INFORMATION I hereby authorize the disclosure of confidential information. I also agree that information about behavior, medical conditions, medications, education, and/or treatments may be communicated among personnel at these offices for the purpose of care, education, and treatment in connection with records regarding the above listed individual. Student’s Name: DOB:

I hereby authorize and request: Agency/Organization/Person

Address

City State Zip Code

Phone: Fax# Email

Check one ☐ Disclose to ☐ Receive From ☐ Exchange information with

Agency/Organization/Person Chileda

Address: 1825 Victory Street

City: La Crosse State: WI Zip Code: 54601

Telephone Number 608-782-6480 Fax: 608-782-6481

Check information to be disclosed Please check ☐ Behavior Assessments ☐ Individual Education Plan and Evaluations ☐ Current Behavior Programs ☐ Medical Reports ☐ Treatment Plans ☐ Social History ☐ Neurological Assessments ☐ Medication ☐ Progress Notes ☐ Psychiatric Evaluation, diagnosis, progress summaries ☐ Discharge Summaries ☐ Occupational, Physical, and Speech Therapy ☐ Lab Results Evaluations ☐ Psychometric Testing/ Psychological Evaluation

I understand that I may revoke this authorization, in writing, at any time except where information has already been released as a result of this authorization. The authorization will automatically expire one year from the date of signature unless authorization is granted through the term of individual’s enrollment at Chileda.

The form must be signed and dated by participant or parent or guardian who is legally authorized to request disclosure. Signature of Participant Date Signed

Signature of Parent or Legal Guardian Date Signed

Signature of Court Appointed Designee Date Signed

As advanced by my signature above I hereby authorize the disclosure of records to person or agency as specified. Dates of authorization From: To: ☐ I choose authorization to expire on the date of participants discharge from Chileda Program. Initial ______

Effective January 2017 Day School Consent Forms Page 17of 23