Clarinda, Iowa 51632

Clarinda Academy 1820 N. 16th Street Clarinda, Iowa 51632

Clarinda Academy, a residential placement is managed and operated by Sequel Youth and Family Services and located at the aforementioned address located on the campus of the Clarinda Treatment Complex. There are several agencies residing on this site and these agencies share in many of their daily operations, such as: food services, health services, recreational activities, etc.

Your child/ward has been accepted into our school. The following information is required in order to provide quality services to your child.

General Information: Student’s Legal Name: ______Date of Birth: ______(Please attach a certified copy of the Birth Certificate) Social Security Number: ______(please attach a copy of the card) Student’s Legal Guardian’s Name: ______

Medical Information: Medical Conditions, medications or allergies that your child/ward may have at the time of admission: ______

Medical Insurance/Medicaid Information (check those that apply)  Private Insurance Plan If you or your child possesses private health plan, please complete the Medical Care Information below. Also, please send a copy of the front and back of the insurance plan card.

Policy Holder’s Name as it appears on the card: ______Policy Holder’s Date of Birth: ______Relationship to Student: ______Policy Holder’s ID Number: ______Group Number: ______Employer’s Name and Address: ______Name and address of Insurance Company: ______Policy Covers (check those that apply):  Major Medical  Eye Care  Dental  Prescriptions  Medicaid (Title 19) Title 19 Number: ______Please send a copy of the most recent Title 19 card you have received. If you receive cards in the future, please forward them to us to ensure the utmost quality of care for your child/ward. I state that the information given is correct to the best of my knowledge. I also give authorization for payment of hospital benefits directly to the hospital and medical benefits directly to the physician(s). I agree to pay any and all hospital, medical, pharmacy, co-pays and deductibles that exceed or that are not covered by my medical insurance, Title XIX or State Medical Coverage that are a result of care for my child/ward.

Legal Guardian/Parent’s Initial here ______

2/3/2012 knm 1 In order to allow your child/ward the maximum opportunities and services provided while placed at the Clarinda Academy we request your permission and are obtaining Informed Consent for the following:

 Informed Consent to Treatment I apply and consent to such psychiatric, psychological, mental health assessment(s), medical, medical screening and follow-up, dental exam(s) and all necessary dental treatment, diagnostic, immunizations to include, but not limited to, MMR, meningitis, Guardisil (females only) and/or other immunizations to ensure healthy living. I also apply and consent to substance abuse assessment & treatment as deemed necessary, emergency and hospital treatment including anesthesia, as professionals utilized/contracting with Clarinda Youth Corporation, d.b.a. Clarinda Academy may prescribe and/or deem necessary to maintain the health of my child/ward. I am aware the practice of medicine, dentistry and mental health is not an exact science, and I acknowledge that no guarantees have been made to me regarding the results of treatment or examinations. Legal Guardian/Parent Initials here ______Students Initials here ______

 Informed Consent/Reciprocal Authority for Release and/or Exchange of Information I authorize the release and/or exchange of all necessary information (written or verbal) to and among the service providers listed below, as well as, other providers contracting and/or providing services for the purpose of health, educational, residential and/or temporary shelter care to my child/ward. All information shared/requested shall be on a “need to know” basis and comply with the Privacy Practices (HIPAA) of Clarinda Academy. The list below is an overview of health care providers for the students entrusted to our care. However, your child/ward may require other treatment /services from a provider not listed. Clarinda Academy will attempt to provide prior notice of service provision; however, it will not at anytime jeopardize the safety and well being of students placed in our care to meet this notification criterion. Routinely utilized providers include, but may not be limited to: Clarinda Academy, Department of Human Services (to include any past child abuse reports), Juvenile Court Services or other child placing agency(s), Youth’s Attorney, Guardian ad Litem, Sports Medicine Providers, Dr. Krishna Murthy, MD; Dr. McNeely, DDS; Clarinda Regional Health Center and it’s affiliated providers, Clarinda Medical Associates, Shenandoah Memorial Hospital and it’s affiliated providers, Montgomery Memorial Hospital and it’s affiliated providers, Area Education Agencies and the child’s resident school district. Other providers may be necessary to ensure the health/wellbeing of your child/ward as determined necessary by individuals directly involved with your child/wards care. Legal Guardian/Parent Initials here ______Students Initials here ______

 Informed Consent to Interview Note: As an integral part of programming at Clarinda Academy we encourage involvement in the various academic, athletic, and job opportunities offered on and off campus. At times, outside entities, such as schools, individuals conducting research, local and national media request filming, photographs and or interviews with our students as recognition of an individual or group accomplishment. Consent: I authorize Clarinda Academy to allow the name and/or filming/photograph of my child/ward to be made public either through the Clarinda Academy newspaper, internet, marketing materials/video/CD/DVD, media or other publication(s). Legal Guardian/Parent Initials here ______Students Initials here ______

2/3/2012 knm 2  Informed Consent to Work Note: As previously stated students at Clarinda Academy may have the opportunity to engage in job opportunities on and/or off campus. This allows students to work toward completion of restitution and/or community service obligations or begin saving for their future. Consent: I authorize Clarinda Academy to allow my child/ward to participate in employment opportunities either on or off campus while placed at Clarinda Academy. Legal Guardian/Parent Initials here ______Students Initials here ______

 Informed Consent to Travel and Participate Note: This consent allows your child/ward to engage in athletic, educational and recreational activities as a representative of Clarinda Academy to accompany Clarinda Academy staff and students to off campus events or trips. Due to our geographical location many of these trips may be outside the state of Iowa, to include but not limited to Nebraska and Missouri. Consent: I understand that all activities involve the risk of injury. I consent/request my child/ward be given the opportunity of participating in interscholastic sports, off campus activities, field trips, etc. Legal Guardian/Parent Initials here ______Students Initials here ______

 Notice of Privacy Practices Acknowledgement Note: “HIPAA”, State and Governmental privacy guidelines were implemented to protect you and your child/ward’s health information. Clarinda Academy has developed a privacy plan in order to comply with these guidelines. Enclosed with the aforementioned consent(s)/medical information request please find a copy of this plan. This copy is yours to keep for your review. By initialing/signing below you acknowledge receipt of this privacy plan. Legal Guardian/Parent Initials here ______Students Initials here ______

I have read and understand the information above. I understand that my initials are the same as my signature in this document. I understand I can terminate the informed consent to any or all by way of written form to Clarinda Academy.

Legal Guardian/Parent Signature: ______Date: ______Legal Guardian/Parent Printed Name: ______Student’s Signature: ______Date: ______Student’s Printed Name: ______

Clarinda Academy is a JCAHO accredited organization.

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