New Beginnings 7437 Lawrence County Ave. LaRussell, Missouri 64848

Transcription

1 New Beginnings 7437 Lawrence County Ave. LaRussell, Missouri STUDENT RECORD RELEASE Dear Counselor: The parent(s)/guardian(s) of have requested that his/her records be transferred. Please release his/her academic and health record to the receiving school named above. Please include cumulative folder and any withdrawn grades. Child s Age: DOB: RELEASING SCHOOL: School Name: School Address: City: State: Zip: Phone: Fax: Receiving Principal Date We will not send for these records until your child is enrolled in New Beginnings

2 CONSENT FOR TREATMENT OF MINOR CHILD As the parent(s)/guardian(s) of, I/we have entrusted his/her care to New Beginnings, located in, Missouri. I give my permission to the above listed institution to serve as my agent in giving consent for any medical, surgical, or dental services to be given under the supervision of a physician or dentist licensed in the state of Missouri. This consent includes disposal of any tissue severed during the treatment process. I understand I am giving this permission before health care is required for my child so that care can be given without undue delay according to the judgment of the above listed institution and the attending physician or dentist. This authorization shall remain in effect until the termination of my child s enrollment at New Beginnings. I understand that authorization for treatment also includes responsibility for paying fees related to services provided with the consent of the above listed institution acting on my behalf. ATTENTION MEDICAL PROVIDER: New Beginnings or its agents are NOT responsible for any fees incurred by the above named student. FATHER/GUARDIAN S FULL NAME (print) FATHER/GUARDIAN S ADDRESS (print) HOME PHONE: ( ) WORK PHONE: ( ) CELL PHONE: ( ) FATHER/GUARDIAN S SSN: - - FATHER/GUARDIAN S SIGNATURE: MOTHER/GUARDIAN S FULL NAME (print) MOTHER/GUARDIAN S ADDRESS (print) HOME PHONE: ( ) WORK PHONE: ( ) CELL PHONE: ( ) MOTHER/GUARDIAN S SSN: - - MOTHER/GUARDIAN S SIGNATURE: IN WITNESS WHEREOF, I/WE have hereunto set my/our hand(s), this day of, 20 STATE OF, COUNTY OF On this day of in the year of, before me, the undersigned notary public, personally appeared, known to me to be the person(s) whose name(s) is/are subscribed to the above instrument and acknowledged to me that he/she/they executed the same for the purposes therein stated. In witness whereof, I hereunto set my hand and official seal. My Commission Expires: Notary Public

3 INSURANCE INFORMATION INSURANCE COMPANY ADDRESS PHONE POLICY HOLDER (full name) POLICY HOLDER S SSN POLICY HOLDER S DOB POLICY HOLDER S EMPLOYER GROUP NUMBER POLICY NUMBER Is prior authorization required for treatment? ( ) YES ( ) NO Give authorization number Dental Insurance Coverage? ( ) YES ( ) NO If YES please attach policy information Appropriate insurance cards must accompany form (Place Copies Here)

4 MEDICAL HISTORY (To be completed by parent required of everyone) Child s Full Legal name: Mailing Address: City: State: Zip: SSN: - - DOB: / / Race: STUDENT HEALTH HISTORY (Check all that the student has or has had) ( ) Drug Flashbacks ( ) Diabetes ( ) Epilepsy ( ) Rheumatic Fever ( ) Arthritis ( ) Scarlet Fever ( ) Frequent Head or Chest Colds ( ) High blood pressure( ) Anemia ( ) Low blood pressure ( ) Tuberculosis ( ) Mumps ( ) Thyroid disease ( ) Measles ( ) Sinus disorders ( ) Chickenpox ( ) Jaundice ( ) Whooping cough ( ) Malaria ( ) Venereal disease ( ) Kidney/Bladder disease ( ) Heart disease ( ) Pleurisy ( ) Liver disease ( ) Weight loss exceeding 10 + ( ) Allergies ( ) Insomnia ( ) Tonsillitis ( ) Diphtheria ( ) Eye trouble ( ) Migraines If YES please explain below FAMILY HEALTH HISTORY (Parents, Grandparents, Siblings) ( ) Allergies ( ) Venereal disease ( ) Mental disease ( ) Brain tumors ( ) Arthritis ( ) Epilepsy ( ) Heart disease ( ) Tuberculosis ( ) Cancer ( ) Diabetes ( ) High blood pressure ( ) Drug or alcohol addiction ( ) Leukemia ( ) Kidney disease Date of last Tetanus or DPT injection:

5 History of injuries: If any, give short account. If none, indicate NONE. History of surgeries: If any, When? What? If none, indicate NONE. List any current medications this child is on and the reasons: Have you ever sought psychiatric or psychological counseling for this child? ( ) YES ( ) NO (If yes, please explain in a letter, including the circumstances and medications prescribed)

6 TO BE COMPLETED BY A PHYSICIAN Physician: Address: City: State: Zip: Phone: Fax: Child s Name: Date: DOB: Height: Weight: Blood Pressure: Temperature: Pulse: Vision w/o corrective lenses: R / L / Vision with corrective lenses: R / L / Heart: Lungs: Abdomen: Extremities: Reflexes: Muscle strength: Genitals: Skin: UA: (glucose) (Albumin) (Microscopic) TB results: Chest x-ray, if positive: The following tests are REQUIRED: TB HIV The following blood tests are RECOMMENDED: VDRL: CBC: Does this person seem to be physically capable of being enrolled in school? ( ) YES ( ) NO If NO, please explain: Comments:

7 Limited Power of Attorney KNOW ALL MEN BY THESE PRESENT, that I/we, do make, constitute, and appoint any authorized official of New Beginnings as my/our true and lawful Attorney, for the limited purpose herein stated and in my/our name(s), place and stead, as my/our act and deed to do the following: To incur any debts deemed necessary by my/our Attorney-In-Fact for the medical care of my/our child, and to execute all documents deemed necessary by the provider of those medical services with full authorization to admit my/our child,, to any hospital for medical examination or treatment. GIVING AND GRANTING unto my/our Attorney-In-Fact power and authority to do and perform all and every act in the exercise of my/our parental rights concerning my/our child,, which I/we might or could do in my/our own person if actually present. And I/we hereby declare that any act or thing lawfully done by my/our said Attorney-In-Fact shall be binding on me/us, my/our heirs, legal and personal representatives, provided the same shall have been done pursuant to the Power of Attorney, and shall have been done prior to revocation of this instrument. I/we understand that the termination of my/our child s enrollment at New Beginnings shall constitute the revocation of this instrument effective on that date. IN WITNESS WHEREOF, I/we have hereunto set my/our hand(s), this, 20., day of STATE OF COUNTY OF On this day of in the year, before me, the undersigned notary public, personally appeared known to me to be the person(s) whose name(s) is/are subscribed to the above instrument and acknowledged to me that he/she/they executed the same for the purposes therein stated. In witness whereof, I hereunto set my hand and official seal. My Commission Expires: Notary Public

8 CONSENT OF PARENT OR GUARDIAN SECTION I I/we agree that I/we will hold harmless and not bring suit against New Beginnings or its agents or employees for any injury, harm or other dangers, whether caused by its agents, employees, or by third parties. Nor will any action be brought for the acts of the child named. This consent authorizes the use of pictures or other audio or visual in which my/our child may appear or any other media in which said child may appear. This consent authorizes the release of school information pertaining to said child to New Beginnings for its private use and evaluation. This consent authorizes the release of any information regarding said child to any of the New Beginnings staff as well as any outside individual with whom New Beginnings staff recommends consultation. I/we agree not to remove my/our child prior to the expiration of the written agreement, I/we understand that my/our child must remain enrolled for at least one full year. In case of early withdrawal, the initial twelve (12) month period, the remaining tuition for that period will become due and payable effective the date of my/our child s termination. In the event that my/our child should run from the premises any tuition and/or entrance fees will not be refunded nor will the remaining tuition for the 12 month contractual agreement become due and payable. I/we assume responsibility for the total cost of any medical, dental, or emergency needs that may arise during my child s enrollment at New Beginnings. I/we grant my/our child permission to travel to various New Beginnings functions during his/her enrollment. I/we understand these activities may take my/our child to other states as well as Canada or Mexico. In addition, I/we agree to not hold New Beginnings liable for any accidents or injuries that occur while on the road or at any of these functions. I/we am/are hereby enrolling my/our child into New Beginnings, and I/we recognize that the aforementioned ministry is no more than a private boarding academy for children, and I/we have chosen this as the proper academic and social environment for my/our child FATHER/GUARDIAN S SIGNATURE: DATE: MOTHER/GUARDIAN S SIGNATURE: DATE:

9 CONSENT OF PARENT OR GUARDIAN SECTION II I have read and agree to abide by all of the above. I have also read, understand, and give my consent to have my child governed by all policies, rules, and regulations of New Beginnings, and to have corporal discipline administered to my child in accordance with those rules. SIGNATURE OF FATHER/GUARDIAN SSN PHONE NUMBER ADDRESS SIGNATURE OF MOTHER/GUARDIAN SSN PHONE NUMBER ADDRESS IN WITNESS WHEREOF, I/we have hereunto set my/our hand(s) this, 20. day of STATE OF COUNTY OF On this day of, 20, before me, the undersigned notary public, personally appeared, known to me to be the person(s) whose name(s) is/are subscribed to the above instrument and acknowledged to me that he/she/they executed the same for the purposes therein stated. In witness whereof, I hereunto set my hand and official seal. My Commission Expires: Notary Public

10 CONSENT AND RELEASE FORM FOR CHURCH/SCHOOL ACTIVITY I/we the undersigned parent(s)/guardian(s), hereby consent to my/our child,, who is years of age, to participate in the activities connected with New Beginnings. I understand these activities will include, but not be limited to the following: horseback riding, swimming, boating, canoeing, fishing, tubing, and other water related sports, football, soccer, basketball, baseball, softball, volleyball, golf, weight lifting, bowling, go-carting, and any other competitive sport, also including any work experience in and around New Beginnings. I certify that my/our child is able to participate in any and all of these activities. If my/our child has medical conditions, which may be relevant to a physician in the event of an emergency, I have listed them below. In the event that an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached in a reasonable amount of time, as determined by New Beginnings staff, I hereby authorize said officials to make emergency medical decisions for my/our child. If there are any activities I do not want my child to be involved in, I have listed them below. I UNDERSTAND AND HEREBY AGREE TO THE EXTENT THAT SUCH AGREEMENT DOES NOT VOID OR MAKE VOIDABLE ANY UNDERLYING INSURANCE COVERAGE WHICH I CARRY, TO ASSUME ALL OF THESE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do, for myself and for my/our child, heirs and assigns, hereby irrevocably and unconditionally release, acquit, and forever discharge New Beginnings and its agents, employees, and volunteers from any and all liability, actions causes of actions, claims, expenses, obligations, and damages of any nature whatsoever, which I now have or which may arise in the future, in connection with my child s participation in the described activity or any other associated activities including, but not limited to, any injury to my child or property, even injury resulting in death. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the state of Missouri and that if any portion hereof is held invalid it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto.

11 CONSENT AND RELEASE FORM FOR CHURCH/SCHOOL ACTIVITY - PAGE 2 I/we further state that I/WE HAVE CAREFULLY READ AND UNDERSTOOD THE FOREGOING RELEASE, AND KNOW THE CONTENTS HEREOF, AND I/WE SIGN THIS RELEASE AS MY/OUR OWN FREE ACT. I understand that this is a legally binding agreement. Medical conditions to be aware of: Physical restrictions: Instructions and medications: Date of last tetanus or booster: I do not wish for my child to participate in the following: IN WITNESS WHEREOF, I/we have hereunto set my/our hand(s), dated this, 20. day of STATE OF COUNTY OF On this day of, 20 before me, the undersigned notary public, personally appeared, known to me to be the person(s) whose name(s) is/are subscribed to the above instrument and acknowledged to me the he/she/they executed the same for the purposes therein stated. In witness whereof, I hereunto set my hand and official seal. My Commission Expires: Notary Public

12 New Beginnings 7437 Lawrence County Ave. LaRussell, Missouri ACKNOWLEDGEMENT OF NOTICE OF PARENTAL RESPONSIBILITY I/we acknowledge that I/we have read and accepted the information contained in the Notice of Parental Responsibility provided by New Beginnings. IN WITNESS WHEREOF, I/we have hereunto set my/our hand(s), dated this, 20. day of STATE OF COUNTY OF On this day of, 20, before me, the undersigned notary public, personally appeared, known to me to be the person(s) whose name(s) is/are subscribed to the above instrument and acknowledged to me that he/she/they executed the same for the purposes therein stated. In witness whereof, I hereunto set my hand and official seal. My Commission Expires: Notary Public

13 New Beginnings 7437 Lawrence County Ave. LaRussell, Missouri PROPERTY RIGHTS FORM I/We, the undersigned parent(s)/guardian(s) of my/our minor child,, agree with the New Beginnings policy that at any such time that my/our child shall have his/her enrollment terminated, for any reason; I/we shall relinquish all rights to any personal property which he/she may have left behind, and agree that New Beginnings may dispose of the property left behind at its discretion. IN WITNESS WHEREOF, I/we have hereunto set my/our hands, dated this day of, 20. STATE OF COUNY OF On this day of, 20, before me, the undersigned notary public, personally appeared, known to me to be the person(s) whose name(s) is/are subscribed to the above instrument and acknowledged to me that he/she executed the same for the purposes therein stated. IN WITNESS WHEREOF, I hereunto set my hand and official seal. My Commission Expires: Notary Public