Application for Boarding 7 th -12 th & Day Students Grades K-12 th Crow Creek Admissions Application Check List ALL APPLICATIONS MUST HAVE THE FOLLOWING LIST OF DOCUMENTS. THE ADMISSIONS COMMITTEE WILL NOT REVIEW INCOMPLETE APLICATIONS. STUDENT_____________________________________________ Grade applying for___________________ Date__________________________________________________ School Year_________________________ Student Enrollment Form Fill out and sign Day Student Check Out Form (Notarized/Mandatory) Social History Form Fill out and sign Permission/Participants Consent Forms Fill out and sign BIE McKinney-Vento Enrollment Form Fill out and sign FERPA Sign & Date The following documents are required before the application can be processed. Copy of State Issued Birth Certificate Copy of Social Security Card Copy of Certified Degree of Indian Blood (Tribal membership card not accepted) Copy of Health/Medical Insurance Cards Physical Forms (if participating Immunization Records
Transcript
Application for Boarding 7th-12th & Day Students Grades K-12th
Crow Creek Admissions Application Check List
ALL APPLICATIONS MUST HAVE THE FOLLOWING LIST OF DOCUMENTS. THE ADMISSIONS COMMITTEE WILL NOT REVIEW INCOMPLETE APLICATIONS.
Date__________________________________________________ School Year_________________________
Student Enrollment Form Fill out and sign
Day Student Check Out Form (Notarized/Mandatory)
Social History Form Fill out and sign
Permission/Participants Consent Forms Fill out and sign
BIE McKinney-Vento Enrollment Form Fill out and sign
FERPA Sign & Date
The following documents are required before the application can be processed.Copy of State Issued Birth Certificate Copy of Social Security Card
Copy of Certified Degree of Indian Blood(Tribal membership card not accepted)
Copy of Health/Medical Insurance Cards
Physical Forms (if participating in sports) Immunization Records
ALL students must provide final report cards and/or Transcripts as of May 2016
Court Appointed or Legal Guardian MUST provide LEGAL DOCUMENTATION.
The first day of school is September 1, 2016. To be considered for Perfect Attendance, Awards and Academic Honors you must be present on September 1.
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STUDENT ENROLLMENT APPLICATIONFOR Crow Creek Tribal Schools
Name of Student: (Last) (First) (Middle)
Address: P.O. Box Street:
City: State: Zip Code
Date of Birth: Month Day Year Sex: Male ( ) Female ( )
Social Security Number________________________________
Tribal Affiliation: Degree of Indian:
Enrollment Number: Home Agency:
Dominant Language spoken in the home:(1) (2)
FAMILY INFORMATIONIMPORTANT-PLEASE NOTIFY THE ADMISSIONS OFFICE IMMEDIATELY IF ADDRESS
OR PHONE NUMBERS CHANGE.Father/Guardian
Address:
Occupation (Optional) Employer:
Telephone Home:
Cell Phone:
Work:
E-mail:
Other (Specify):
Mother/Guardian
Address:
Occupation (Optional) Employer:
Telephone Home:
Cell Phone:
Work:
E-mail:
Other (Specify):
Emergency Contact
Phone No.
Relationship to Student
If you are a court appointed custodial parent or guardian, you must attach the appropriate documentation
I affirm that all information on this form is accurate to the best of my knowledge
_________________________________________ _______________________________________Parent/Guardian Signature Parent/Guardian Print Date
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Student Name
EDUCATIONAL INFORMATION
1. List school previously attended:
2. Previous school contact number:
3. Reason for leaving:
4. Did student miss 15 or more days in the last school year? ( )Yes ( ) No
5. Has student ever been suspended? ( ) Yes ( ) No Expelled? ( ) Yes ( ) No
If yes date and reason must be given:6. Has student participated in Special Education Program? ( ) Yes ( ) No
7. Has student participated in Talented and Gifted Program? ( ) Yes ( ) No
8. Will your student participate in sports? ( ) Yes ( ) No
If so complete ALL sports/physical information forms.
SOCIAL INFORMATION
1. Is student a ward of the court? ( ) Yes ( ) No
If yes a copy of the court order must be submitted.
2. Has student ever been arrested? ( ) Yes ( ) No
If yes what was/were the violations?
3. Has student ever been in jail or a detention center? ( ) Yes ( ) No
If yes how many times?
4. Does student have a probation officer? ( ) Yes ( ) No
Name_________________________________
County________________________________
Phone_________________________________
5. Has student ever received counseling? ( ) Yes ( ) No
Name_________________________________
Phone_________________________________
I affirm that all information on the above mentioned student is true and accurate to the best of my knowledge. Any false statement or misrepresentation or omission of required information in this application will result in denial of this application.
_________________________________________ _________________________________________Student Signature Parent/Guardian Date
Crow Creek Tribal Schools/Transcripts/Records ReleaseHigh School/Middle School
Home Phone:___________________________ Cell or emergency #______________________________ I authorize the Principal, Counselor, Registrar and Special Education staff at:
Name of Previous School attended: ________________________________________________________
Address of Previous School:_________________City:_______________State:________Zip__________
Dates Attended: ___________________________ to _________________________Month/Year Month/Year
To release the following information: Crow Creek Tribal Schools Transfer Grades Last Report Card Transcripts Attendance Behavior Report Standard Test Results
English Language Proficiency 504 Plan, Talented and Gifted Records Immunizations, Birth Certificate Degree of Indian Blood
Special Education Records-please include: current or last IEP, Parental Consent, Team Summary, Evaluation Report, Current Psychological Evaluation Report
Other if any:____________________________________________________________________
_______________________________ ________________________________ __________Student Signature Parent/Guardian Signature Date
FEDERAL LAW 99-31-*THERE IS NO PARENT SIGNATURE REQUIRED FOR EDUCATION RESOURCES TO BE SENT TO ANOTHER AGENCY.*
Crow Creek Tribal SchoolsCampus Portal Acceptable Use Policy
INFORMATION IS USED FOR SCREENING PURPOSES ONLY____YES____NO (Student is currently enrolled in our school)
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Crow Creek Tribal Schools has developed a Campus Portal as a means to further promote educational excellence and to enhance communication with parents and students. The Campus Portal allows parents and students (Grades K-12) to view school records anywhere at any time. In response for the privilege of accessing the Crow Creek Tribal Schools Campus Portal, every parent and student is expected to act in a responsible, ethical and legal manner. The Campus Portal is available to every parent or guardian who has a student enrolled at Crow Creek Tribal Schools. Parents and students are required to adhere to the following guidelines.
1. Parents and students will not share their passwords with anyone, including their children or classmates.2. Parents and students will not attempt to harm or destroy data of their own children, of another user, school or district network, or the Internet.3. Parents and student will not use the Campus Portal for any illegal activity, including violation of Data Privacy laws. Anyone found to be violating laws will be subject to Civil and/or Criminal Prosecution.4. Parents and students will not access data or any account owned by another parent or student5. Parents and students who identify a security problem with the Campus Portal must notify the Schools Technology Coordinator immediately (852-2993) or ([email protected]) without demonstrating the problem to anyone else.6. Parents and students who are identified as a security risk to the Campus Portal will be denied access to the Campus Portal.
User guidelines and system requirements can be found at www.crowcreek.k12.sd.us. Please review them before signing and returning this document. You are required to sign and return this agreement before you receive access to the Campus Portal. Students must both sign and have a parent signature to gain access to the Campus Portal. Please fill in all blanks (Print)
I have read the Campus Portal Acceptable Use Policy and I agree to abide by and support these rules. I understand that if I violate any terms of this Acceptable Use Policy that I may lose my privilege to use the Campus Portal, and may be liable for civil and/or criminal consequences.
Crow Creek Tribal Schools Permission Form for Internet Usage in Classroom and Dormitory Photo Release Religion of Choice Consent
Students at CCTS have access to the internet in computer related classes, as well as in the dormitory
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There are strict rules for Internet usage by students. As a school system we attempt to block out as many inappropriate sites as possible, but as you may have read or heard, this can be difficult at times.
In order for your child to be allowed any contact on the internet, we need to have your permission. Please understand that due to certain circumstances your student may access an inappropriate site. We will not be held liable for any such occurrences.
If it is proved that a student has misused the internet or e-mail services, their privileges may be revoked for the remainder of the school year.
Please check on of the following:_____I Do Not Give Permission for my child to be on the internet. _____I Do Give Permission for my child to be on the internet.I also give permission to use my child’s picture on your website. I understand that staff will monitor student use of the internet and agree not to hold the school liable for any unintentional incident of my child viewing an inappropriate site.
******************************************************************************PHOTO Release Form
All photographers taking photographs or on Crow Creek Tribal Schools property or of Crow Creek Tribal School Events or student works must obtain a signed release form from any student, faculty member, staff person who is visibly recognizable in the photograph. crowd scenes where not single person is the dominate feature are exempt.
These rules govern photographs intended for use in any Crow Creek Tribal School publication of marketing or a public relations nature, such as newsletters, brochures, yearbooks, promotional items, or other such material. Releases also must be obtained for photographs used on the Web. These rules are not in effect when photographs are taken on news events, but photographs taken for news purposed required a release for reuse in marketing materials.
PLEASE CHECK ONE
________I DO give my consent for Crow Creek Tribal School to interview me or my child (name listed below) to use in photograph(s) video in any and all of its publications and in any and all media for use but the Crow Creek Tribal School. I will make no monetary or other claim against Crow Creek Tribal School for the use of the interview and/or the photographs(s) video.
________I DO NOT give my consent for Crow Creek Tribal School to interview me or my child (name listed below, to use in photograph(s)/video in any and all of its publications.
Name of child (Please Print)____________________________________________________
Relationship to child (if child is a minor)_________________________________________
****************************************************************************** Religion of Choice Consent
I, _____ Give Consent _____ Do Not Give Consent - For my child to participate in sweat lodge ceremonies or attend the church of their choice for purposes of purification, prayers or personal spiritual guidance while attending CCTS. My child’s religion affiliation is:_____________________________________________________
Crow Creek Tribal SchoolsDay Students Check out Form 2016/2017
(Dorm Students must use the Dorm Check-Out Form when checking out during school)
It is very important the Parent/Legal Guardian have this form complete and notarized for the safety of our students. Students will not be allowed to check out of the dormitory or school unless they are released to a
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person whose name appears on this permission form. Any other special circumstances will have to be referred to a Principal, Dormitory Supervisor or Superintendent.
_____________________________________ ____________________________________Student Name Home Reservation
_____________________________________ ____________________________________Parent/Legal Guardian Phone # you can be reached at immediately
____________________________________________________________________________________PO Box/Address City State Zip
I hereby give the following adults permission to check out my son/daughter for week-ends or holidays. I understand that these adults must personally pick up the student and sign him/her out from the school
(if during school hours) and from the dormitory. I understand that off reservation students may not check out to Ft. Thompson and surrounding
communities for overnight unless with parents or legal guardian.(Handwriting must correspond to notarized signatures at bottom of the page)
I also give the school permission to seek out adequate housing and transportation for my son/daughter during emergencies.
_____________________________________ ____________________________________Signature of Parent/Legal Guardian Verified by Notary of the Public
____________________________________My Commission Expires on
Family Education Rights and Privacy Act (FERPA)
The Family Education Rights and Privacy Act of 1974, commonly known as FERPA, is a federal law that protects the privacy of student education records. Students have specific, protection rights regarding the release of such records and FERPA requires that institutions adhere strictly to these guidelines.
The following are statements that reflect what the Family Education Rights and Privacy Act (FERPA) covers concerning your rights as a parent and student:
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Parents are allowed to review all files and material the school has about their child. All schools are required to follow FERPA. The schools cannot provide a student with his/her parent’s financial records. A student can request that doctor of his/her choice review psychiatric or treatment
records. FERPA does not allow the students to see the same files and records that their parent can
see. A probation officer cannot see a student’s educational records without parental consent. The school is required to keep a list of all people who access a student’s records. Parents are allowed to bring someone with them to review their child’s school records. Parents are allowed to review their child’s testing protocols. Student Special Education records are the school’s responsibility to safeguard and no file
should ever be left out of place where they can be seen by unauthorized people. Staff members can be reprimanded for failure to safeguard student records.
If you have further questions on your rights under the FERPA law then please feel to contact the school or visit the www (world wide web) and do a search on FERPA. This will pull up the law, its interpretation and how it affects you as a parent/student.
By initialing this form I have read all the above information.
__________________________________________________ ________________Parent/Guardian Date
Crow Creek Tribal SchoolsBIE McKinney-Vento Enrollment/Referral/Residency Form
The Purpose of this form is to address the requirements of the McKinney-Vento Act, Title X. This Document will be used to share with school staff and partnering agencies to ensure all providers have the necessary information to support the child and his/her family.
Student Name: ________________________________________________________ ( ) Male ( ) Female
Please check only ONE that best describes where the student is presently living (Please specify name of hotel, shelter, or organization providing the transitional housing)
In my own home or apartment
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In the home of a friend or relative because I lost my housing. (fire, flood, lost job, divorce, domestic violence, kicked out by parents, parent in the military was deployed, parent(s) in jail). Name/Address and phone of person with whom you live (full name required)____________________________________________________________________________________________________________
In a shelter because I don’t have permanent housing. (living in a family shelter, domestic violence shelter or children/youth shelter) Name/Address of phone of shelter___________________________________________________________________________________________________________
In Transitional housing (housing that is available for a specific length of time only and is partly or completely paid by a church, a nonprofit organization or some other organization) Name/Address and phone of organization providing housing__________________________________________________________________________________________________________
In a hotel or motel (because of economic hardship, eviction, cannot get deposits for permanent housing) Name/Address and phone of hotel or motel where your staying__________________________________________________________________________________________________________
In sheltered care (living in a car, park, campground). Provide where you are living such as where you car is parked._____________________________________________________________________________________
In housing that does not have plumbing, electricity or heat. (circle all that apply)
Awaiting foster care placement
None of the above (describe my current living situation. Briefly describe your situation. Address/Directions____________________________________________________________________________________
Name of parent/guardian or person who student resides with____________________________________________
____________________________________________________________________________ ___________________Signature of Parent/Guardian or person who student resides Date
Dear Parent or Guardian:
The Indian Health Service is asking you to complete and sign the attached Consent Form (IHS-47)
DEPARTMENT SERVICES OF HEALTH & HUMAN Public Health Service
Indian Health Service
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in order to arrange for or provide health services for your child/children while in attendance at school. This includes medical and dental care (including emergency services when necessary).
The attached Consent Form for School Health Services provides information about the service avail-able while your child attends school. If you desire to share your responsibility for the health care of your child, the Indian Health Service must have a signed consent form in his/her health record. You have the right to approve the entire consent form or write your exceptions or special instructions in The space provided.
The Indian Health Service will collect the information for proper health care and use the information to treat you child or for the purpose described on the back of the Consent Form.
You are urged to sign this Consent Form which is for the current school. A new form will be required for each school year. Please return this form to the school or the local IHS clinic.
Thank You very much for your assistance.
Attachment
_________________________________ ClinicPHS Indian Health Service
IHS-47 (10/88)
DEPARTMENT OF HEALTH AND HUMAN SERVICESPUBLIC HEALTH SERVICEINDIAN HEALTH SERVICE
CONSENT OF PARENT OR LEGAL GUARDIAN OR OTHER PERSON 1
WHO HAS PRIMARY RESPONSIBILITY FOR THE CARE OF THE CHILD
(Before completing this form, please read information on reverse side.)
Name of BirthStudent_____________________________________________ Date________________________________
I (We),____________________________________________________________________________________Have read the Consent Form for the Indian Health to arrange for or to provide the following health services for this child:
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1. Health care including medical examinations, routing laboratory studies, x-ray procedures, and skin tests.
2. Dental care including dental examinations, preventive use of fluorides and necessary emergency dentalcare.
3. Mental health services including evaluation and treatment as necessary.
4. Emergency health care for accidents or illness.
5. Transportation of the child to and/or form another health facility for these services.
I hereby give consent for all the above services.
Exceptions or Special Instructions:____________________________________________________________________________________
Signature of Patient Representative Date(State relationship to patient or witness (if signature is by thumb print or mark)
___________________________________________ ________________________Signature and Title of IHS Employee Date
FOR PATIENTS UNABLE TO ACKNOWLEDGE RECEIPT
I HEREBY CERTIFY THAT THE PATIENT WAS UNABLE TO ACKNOWLEDGE RECEIPT OF THE IHS NOTICE OF PRIVACY PRACTICES BECAUSE____________________________________________________________________
___________________________________________ ________________________Signature of IHS Employee Date
CROW CREEK SERVICE UNITFT. THOMPSON HIS HEALTH CENTER
BUSINESS OFFICEPO BOX 200
FT. THOMPSON, SD 57339(605) 245-1540
AUTHORIZATION TO FURNISH INFORMATION AND ASSIGNMENT OF BENEFITS
I authorize Ft. Thompson IHS Health Center to release medical information about me to my insurance carrier, workmen’s compensation carrier or SD Medicaid.
I hereby assign insurance benefits that I may be eligible to receive, to the Ft. Thompson IHS Health Center as payment for medical services and supplies furnished to me by the IHS. I authorized direct payment of such benefits to the Indian Health Service, Ft. Thompson, SD 57339.
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____________________________________________Patient’s Name
THIS CONSENT SHALL REMAIN VALID UNTIL REVOKED IN WRITING
NOTICE TO PATIENTS
ELIGIBILITY FOR DIRECT CARE:You must be eligible for DIRECT CARE. This care provided at the Ft. Thompson IHS Health Center. To be eligible for DIRECT CARE you must be an Indian/Native American from a Federally Recognized Tribe of the United States. You may reside anywhere within the United States. You are allowed up to 30 days to provide proof of being Indian/Native American and allowed 1 clinic visit. Proof shall be in the form of a letter, statement, or BIA Form 4432 from your Tribe, Which contains either enrollment number or degree of Indian Blood OR if NOT enrolled, proof of decadency/Lineage. It is the responsibility of the patient to obtain this proof. If proof is not shown within the time frame specified further services WILL NOT be allowed at the Ft. Thompson IHS Health Center.
A medical doctor of the IHS may refer a person when the medical care required cannot be provided by the Ft. Thompson IHS Health Center. IHS WILL NOT AUTHORIZE PAYMENT for this care until the following eligibility requirements are met.
ELIGIBILITY FOR PATIENT REFERRALS:You must be eligible for CONTRACT HEALTH CARE. This is care provided away from the IHS Facility. You must first meet the Direct Care requirements and you must reside within a delivery area called the “ON or NEAR Regulation” The “ON” refers to an Indian/Native American eligible for Direct Care and lives within the boundaries of the Crow Creek Sioux Reservation. The “NEAR” refers to the members of the Crow Creek Sioux Tribe who live near the Crow Creek reservation where the Ft. Thompson IHS Health Center is located. Members of the Crow Creek Sioux Tribe who reside within our
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CHS delivery is (i.e., Buffalo, Brule, Hand, Hughes, Hyde, Lyman, and Stanley Counties) will meet the “NEAR” regulation. If the patient is not enrolled with the Crow Creek Sioux Tribe and “DOES NOT” live on the Crow Creek Reservation the patient “IS NOT” eligible for Contract Health Services.
If the patient does not meet BOTH eligibility requirements for DIRECT CARE and Contract Health Care, “IHS WILL NOT PAY” for care provided at a non-IHS health care facility.
NON-INDIAN BENEFICARIES:Any Non-Indian woman pregnant with an eligible Indian/Native American child will be required to show proof that she is eligible for prenatal and postnatal services either through marriage to an eligible Indian/Native American male or by statement from the eligible Indian/Native American that she is carrying his child.
I have read & received a copy of the above information.
______________________________________________ __________________Signature Date
Ft. Thompson IHS #________________
PATIENT REGISTRATION INFORMATION
In order for the Ft. Thompson Indian Health Center to continue providing efficient health services to you and your family, we must update your demographic information at every visit. This statistical information assists the Indian Health Center in providing a variety of services to you. If you have any questions please ask the Patient Registration Clerk or Patient Benefits coordinator for assistance.Patient Information:
____________________________________________________________________________________________________________Last Name First Name Middle Name Date of Birth Social Security Number
____________________________________________________________________________________________________________Birth Place – City and State Male or Female Current Community Date Moved There
____________________________________________________________________________________________________________Marital Status ALIAS Used (name) Religious Preference
____________________________________________________________________________________________________________Mailing Address – City, State, Zip Code Home Phone # Work Phone # Cell or Message Phone #
____________________________________________________________________________________________________________Name of Tribe Blood Quantum Tribal Enrollment #
** If you do not have your Tribal Enrollment Card/Paper with you, you will need to sign a 30 day notice****If you are not enrolled with any Tribe you must show proof that you a Tribal Descendent**
Parent Information **Please write DEC – Behind Name if Deceased**
Alternative Resource Information:**This information is necessary for billing and other resources such as MEDICAID or other Health Insurance**
**Insurance is billed directly to the carrier and not to you as the patient**
Are you covered by MEDICAID? Yes No PLEASE SUBMIT CARD FOR FILEIf Yes, ID ______________________________________ (Brown Card)
Are you covered by MEDICARE? Yes No PLEASE SUBMIT CARD FOR FILEIf Yes, ID ______________________________________ (White Card with Red & Blue Stripe)
Are you covered by Private Health Insurance? Yes No PLEASE SUBMIT CARD FOR FILEIf Yes, ID ______________________________________
Name of Insurance Company______________________________________________ Effective Date_____________________
Group #_________________________________________
Name(s) of all insured_______________________________________________________________________________
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Veterans Information
Are you a Veteran? Yes No If Yes, what is you Serial Number_________________________
Branch of Service ________________________Entry Date _________________________ Discharge Date_____________________
Vietnam Connected? Yes No Service Connected Disability? Yes No
Other Patient Data:
What Race are you? (Circle one) American Indian or Alaska Native/Asian/African American/White/Other
Are you Hispanic or Latino? Yes No Unknown
What is your Primary Language? Do you need an Interpreter? Yes No
What is your Preferred Language?
Do you have access to the Internet? Yes No If Yes, Where?
Do you have an Email address? Yes No
If Yes, What is your email address? _______________________________________________
What is your preferred method of Contact? (Circle one) Mail Email Phone____________________________________________________________________________________________________________**You should have received a NOTICE OF PRIVACY PRACTICES, ASSIGNMENT OF BENEFITS FORM, and DIRECT CARE/CHS
INFORMATION FORM for you to sign and date. This information will be electronically filed into our database as well as a hard copy placed in your chart. Please Note that all information you have given is CONFIDENTIAL and will be used only for your
continued Health Care. Thank You for your cooperation**Interview Information:
WAS YOUR INTERVIEW WITH PATIENT REGISTRATION IN A FRIENDLY MANNER? YES NO
DO YOU FEEL SECURE THAT YOUR RIGHTS AS A PATIENT ARE RESPECTED? YES NO
DO YOU FEEL YOUR RIGHTS TO PRIVACY, AS A PATIENT, ARE RESPECTED? YES NO
PATIENT or PARENT/GUARDIAN SIGNATURRE _______________________________________ DATE________________
** THIS CONCLUDES THE PATIENT REGISTRATION PROCESS. PLEASE REVIEW THIS DOCUMENT TO MAKE SURE THAT YOU HAVE FILLED IT OUT COMPLETELY**
THANK YOU
This section to be completed by Patient Registration Staff:
DATE RECEIVED:_________________________ STAFF INITIALS:__________________________
DATE ENTERED:__________________________ STAFF INITIALS:__________________________
