Docstoc

Enrollment Application

Document Sample
Enrollment Application Powered By Docstoc
					         Student and Family Information
         Student Information
         Student Name (First Middle Last Name)                                         Student’s Social Security Number


         Nickname                                 Gender                               Date Received (Office Use)         Date of Enrollment (Office use)
                                                   Male             Female
         Date of Birth                            Age at Admission                     Birthplace                         Country of Citizenship


         Is student adopted?                      Age Adopted                          Student’s Passport Number:         Passport Expiration Date:
            Yes          No
         Permanent Street Address                                                      Telephone Number                   Cellular Telephone


         City                                     State       Zip                      E-mail Address



         Religious Preference (optional)          Race/ethnicity (optional)            Student’s Native Language          Other languages spoken in home


         Height                                   Weight                               Eye Color                          Hair Color



         Custody Information (Copy of all court orders and agreements relating to custody of student must be submitted with this application)
         Biological Parent’s Marital Status
                       Married                Separated               Divorced             Never Married
         Parent/Guardian full name                                                     Relationship                       Type of Custody
                                                                                                                           Joint            Full
         Parent/Guardian full name                                                     Relationship                       Type of Custody
                                                                                                                           Joint            Full


         Father’s Contact Information
         Father’s Full Name (First Middle Last)                                         Living           Deceased       Father’s Social Security Number


         Occupation                                                                    Business Telephone                 Cellular Telephone


         Street Address                                                                Home Telephone                     Other Telephone/Pager


         City                                     State       Zip                      Fax                                E-mail



         Stepmother/Partner’s Name (if applicable)                                     Social Security Number             Occupation


         Business Telephone                       Cellular Telephone                   E-mail



         Mother’s Contact Information
         Mother’s Full Name (First Middle Last)                                         Living           Deceased       Mother’s Social Security Number


         Occupation                                                                    Business Telephone                 Cellular Telephone


         Street Address                                                                Home Telephone                     Other Telephone/Pager


         City                                     State       Zip                      Fax                                E-mail



         Stepfather/Partner’s Name (if applicable)                                     Social Security Number             Occupation


         Business Telephone                       Cellular Telephone                   E-mail



F10015                                                                         Packet Page 1                                                          Revised 06.07.2005
     New Summit Academy                                                                       Student and Family Information, Page 2
         NAME OF STUDENT




         Guardian Information (IF OTHER THAN BIOLOGICAL PARENTS)
         Guardian’s Full Name (First Middle Last)                             Relationship to Student         Social Security Number


         Occupation                                                           Home Telephone                  Cellular Telephone


         Street Address                                                       Business Telephone              Fax


         City                                  State     Zip                  E-mail



         Guardian’s Spouse/Partner (if applicable)                            Date Married                    Social Security Number


         Occupation                            Business Telephone             Cellular Telephone              E-mail



         Financial Sponsor Information (IF OTHER THAN STUDENT’S PARENTS)
         Sponsor’s Full Name (First Middle Last)                              Relationship to Student         Social Security Number


         Agency/Organization Name (if applicable)                             Business Telephone              Cellular Telephone


         Street Address                                                       Home Telephone                  Other Telephone/Pager


         City                                  State     Zip                  Fax                             E-mail



         Emergency Contact Information (TO BE NOTIFIED IF PARENTS CANNOT BE REACHED)
         Name of Emergency Contact                                            Relationship to Student


         Street Address                                                       Home Telephone                  Cellular Telephone


         City                                  State     Zip                  Business Telephone              E-mail



         Name of Emergency Contact                                            Relationship to Student


         Street Address                                                       Home Telephone                  Cellular Telephone


         City                                  State     Zip                  Business Telephone              E-mail



         Sibling Information
                                                                                                                        Lives With
                                     Name of Sibling                                Gender              Age   (Mother, Father, Independently)




         Information Provided By
                           Print Name                               Signature of Parent/Guardian                        Date Signed




F10115                                                                Packet Page 2                                                    Revised 06.07.2005
     New Summit Academy                                                                            Student and Family Information, Page 3
         NAME OF STUDENT




         Referral Information
         How did you FIRST learn about New Summit Academy?
               Educational Consultant               Boarding School                      Relative/Friend             Internet search or
                                                                                                                         website
               Counselor/therapist                  Wilderness Program                   Parent of New Summit
                                                     Substance Abuse Program
                                                                                            Academy student             Other (specify)

         If you obtained information about New Summit Academy from more than one source, check all other sources that apply.
               Educational Consultant               Boarding School                      Relative/Friend             Internet search or
                                                                                                                         website
               Counselor/therapist                  Wilderness Program                   Parent of New Summit
                                                     Substance Abuse Program
                                                                                            Academy student             Other (specify)

         If referred by an individual, please provide the following information
         Name of Referral Source                                                   Title


         Organization Name                                                         Business Telephone              Fax


         Street Address                                                            Home Telephone                  Cellular Telephone


         City                                 State        Zip                     E-mail


         If referred by another school or program, please provide the following information
         Name of Referring School/Program                                         Contact Name (if applicable)


         Street Address                                                            Business Telephone


         City                                 State        Zip




F10115                                                                     Packet Page 3                                                      Revised 06.07.2005
         Student Personal and Behavioral History
         Student Name (First, Middle, Last)                                                                     Date of Birth



          Student’s Current Functioning (ATTACH ADDITIONAL SHEET OF PAPER IF NEEDED TO PROVIDE DETAILED INFORMATION)
         Describe any significant challenges or behavioral issues facing the student. Include primary reason for enrollment in New Summit
         Academy.




         Describe the student’s decision-making ability and willingness to accept responsibility.




         Describe any challenges facing the student in regards to living independently and maintaining employment or school attendance.




          Student’s Behavioral/Emotional History
          PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY, CURRENTLY OR IN THE PAST. FOR ANY “YES” ANSWER, PLEASE PROVIDE
          ADDITIONAL INFORMATION IN THE SPACE BELOW AND ON THE NEXT PAGE; ATTACH ADDITIONAL SHEET OF PAPER IF NEEDED.

         Alcohol use/abuse                                 Yes  No          Sexual activity                                    Yes  No
         Drug use/abuse                                    Yes  No          Physical abuse                                     Yes  No
         Self-harm or self-abusive behavior                Yes  No          Sexual abuse/assault                               Yes  No
         Depression                                        Yes  No          Eating disorder/large weight gains or losses       Yes  No
         Suicide discussion, threat or attempt             Yes  No          Death of parent or sibling                         Yes  No
         Mood or thought disorder                          Yes  No          Death of friend                                    Yes  No
         Aggressive behavior                               Yes  No          Other traumatic event (specify)                    Yes  No
         Arson/fire setting                                Yes  No          Police involvement                                 Yes  No
         Cruelty to animals                                Yes  No          Juvenile Probation                                 Yes  No
         Running away from home or placement               Yes  No          Adult Probation                                    Yes  No
         Stealing                                          Yes  No          Other (Specify):                                   Yes  No

          IF YOU ANSWERED YES TO ANY ITEMS ABOVE, PLEASE PROVIDE ADDITIONAL INFORMATION.
                                        DATE OF LAST
                    ISSUE                                                                       EXPLANATION
                                        OCCURRENCE




F10015                                                                 Packet Page 4                                                  Revised 06.07.2005
      New Summit Academy                                                         Student Personal and Behavioral History, Page 2
        NAME OF STUDENT




         Student’s Relationships
        Describe student’s primary family relationships. Include description of relationship with parents, step-parents and siblings.




        Describe the student’s relationship with adults other than his or her parents.




        Describe student’s peer relationships.




         Student’s Strengths, Interests, Accomplishments and Goals
        Describe the student’s primary strengths.




        Describe the student’s areas of interest and/or major accomplishments.




        Describe parents’ goals for the student following completion of New Summit Academy.




        Describe student’s goals following completion of New Summit Academy, especially if these differ from those of the parents.




         Additional Information
        Has student experienced any specific fears (explained or unexplained) such as fear of water, heights, darkness, thunder, insects,
        animals, death? At what age?



        Provide any additional student or family history that would be helpful in understanding the student’s current needs.




        Any thing else you would like us to know about the student?




         Information Provided By
                          PRINT NAME                               SIGNATURE OF PARENT/GUARDIAN                            DATE SIGNED




Enrollment Application                                                Packet Page 5                                                      Revised Aug3006
           Counseling and Consultations History
           Authorization to Release Information
         Student Name (First, Middle, Last)                                                                     Date of Birth



         As part of the admissions process or during the Student’s enrollment in New Summit Academy it is sometimes beneficial to contact
         professionals (such as educational consultants, school counselors or former therapists) who have previously been involved in the
         assessment, planning or treatment of the Student. New Summit Academy needs parent/guardian permission to contact these
         professionals for information regarding previous evaluations, treatment or planning. In addition, we need to know which of these
         professionals will continue to be involved with the Student and if we are authorized to share information with them regarding the
         Student’s progress in New Summit Academy.
         Please list Student’s educational consultant, therapist, psychiatrist, psychologist, social worker or other professional and
         indicate those professionals who are authorized to receive verbal or written reports from New Summit Academy by
         marking “Yes” in the “Progress Reports Authorized” box. (Use additional copies of this form, if necessary).

         Full Name                                                            Nature of Service


         Agency/Company Name                                                  Dates of Service                  Progress Reports
                                                                              From:               To:                  Yes         No
         Street Address                                                       Business Telephone                Cellular Telephone


         City                                 State   Zip                     Fax                               E-mail



         Full Name                                                            Nature of Service


         Agency/Company Name                                                  Dates of Service                  Progress Reports
                                                                              From:               To:                  Yes         No
         Street Address                                                       Business Telephone                Cellular Telephone


         City                                 State   Zip                     Fax                               E-mail



         Full Name                                                            Nature of Service


         Agency/Company Name                                                  Dates of Service                  Progress Reports
                                                                              From:               To:                  Yes         No
         Street Address                                                       Business Telephone                Cellular Telephone


         City                                 State   Zip                     Fax                               E-mail



         Authorization for Release of Information
         I hereby authorize the professionals listed above to release information regarding the above named Student to New Summit
         Academy of Costa Rica and authorize New Summit Academy of Costa Rica to release information regarding the Student only to
         those professionals flagged above to receive Progress Reports. Information covered by this authorization shall include social
         history, psychological or educational evaluations, treatment plans and progress notes, educational planning, academic records,
         incidents reports, medical records, discharge summaries, and other records that may be helpful in the planning for the Student. This
         authorization shall be effective beginning on the date signed and remain in effect for a period of one year or until _____________
         (expiration date or event). The undersigned understands that he/she may inspect or copy the protected information to be used or
         disclosed and may revoke this authorization in writing by contacting the Admissions Office at the address below, attention Privacy
         Officer. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer
         be protected by HIPAA. The undersigned also understands that he/she may refuse to sign this authorization and that New Summit
         Academy of Costa Rica will not condition enrollment, service availability or payment on the provision of this authorization.
                          Print Name                    Signature of Parent/Guardian and Student (if age 18+)              Date Signed




                                      FAX 1 COPY to: (561) 892-3853
          MAIL ORIGINALS to: Educacion Nueva Cumbre, Box #159-4013, Atenas, Alajuela COSTA RICA
F10016                                                               Packet Page 6                                                        Revised 06.07.2005
           Prior Placements and Interventions
         Student Name (First, Middle, Last)                                                                        Date of Birth



         Please list all prior out-of-home placements, including special purpose boarding schools, wilderness programs, substance
         abuse programs, psychiatric hospitalizations, residential treatment centers, etc.

         Name of School/Program/Hospital                                         Contact Name


         Street Address                                                          Telephone Number                  Fax Telephone Number


         City                                 State, Zip                         Dates of Enrollment/Placement
                                                                                 From:                             To:
         Reason for enrollment/admission




         Departure Circumstances




         Name of School/Program/Hospital                                         Contact Name


         Street Address                                                          Telephone Number                  Fax Telephone Number


         City                                 State, Zip                         Dates of Enrollment/Placement
                                                                                 From:                             To:
         Reason for enrollment/admission




         Departure Circumstances




         Authorization for Release of Information
         The undersigned hereby grant permission to release to New Summit Academy of Costa Rica all available information and/or records
         regarding the above named Student, including social history, psychological or educational evaluations, treatment plans, progress
         reports, therapy notes, incident reports, discharge summary, physical examination and medical reports, academic plans, academic
         transcripts, and other materials that may be helpful in the treatment or education planning for the Student. This authorization shall
         be effective beginning on the date of signature and remain in effect for a period of one year or until the date of the student’s
         discharge from the program. The undersigned understands that he/she may inspect or copy the protected information to be used or
         disclosed and may revoke this authorization in writing by contacting the Admissions Office at the address below, attention Privacy
         Officer. Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer be
         protected by HIPAA. The undersigned also understands that he/she may refuse to sign this authorization and that New Summit
         Academy of Costa Rica will not condition enrollment, service availability or payment on the provision of this authorization.
                          PRINT NAME                       SIGNATURE OF PARENT/GUARDIAN AND STUDENT (IF AGE 18+)              DATE SIGNED




                                      FAX 1 COPY to: (561) 892-3853
         MAIL ORIGINALS to: Educacion Nueva Cumbre, Box #159-4013, Atenas, Alajuela COSTA RICA




F10016                                                                   Packet Page 7                                                      Revised 06.07.2005
         Educational History
         Student Information
         Student Name (First, Middle, Last)                                     Date of Birth                       Social Security Number


         Street Address                                                         City                                State      Zip



         Previous Schools
         Please list all high schools attended (most recent first) with complete addresses and phone numbers. If additional space is needed, make a
         copy of this page or attach an additional sheet.

         Name of School                                                                                             Highest Grade Completed


         Street Address                                                         Dates of Enrollment
                                                                                From:                               To:
         City                                 State     Zip                     Telephone Number                    Fax Number


         Reason for Withdrawal



         Name of School                                                                                             Highest Grade Completed


         Street Address                                                         Dates of Enrollment
                                                                                From:                               To:
         City                                 State     Zip                     Telephone Number                    Fax Number


         Reason for Withdrawal



         Name of School                                                                                             Highest Grade Completed


         Street Address                                                         Dates of Enrollment
                                                                                From:                               To:
         City                                 State     Zip                     Telephone Number                    Fax Number


         Reason for Withdrawal



         Name of School                                                                                             Highest Grade Completed


         Street Address                                                         Dates of Enrollment
                                                                                From:                               To:
         City                                 State     Zip                     Telephone Number                    Fax Number


         Reason for Withdrawal



         Authorization for Release of Information
         The undersigned hereby grant permission to release all available school records for the above named student to New Summit
         Academy of Costa Rica. Permission is granted to release the following records: official transcript of credit; withdrawal grades;
         special education records; IEP; educational assessment results; health records; immunization records; disciplinary reports;
         counseling information and any records pertaining to psychiatric or psychological evaluation of the student.
                          Print Name                      Signature of Parent/Guardian and Student (if age 18+)               Date Signed




                                      FAX 1 COPY to: (561) 892-3853
         MAIL ORIGINALS to: Educacion Nueva Cumbre, Box #159-4013, Atenas, Alajuela COSTA RICA
F10016                                                                  Packet Page 8                                                         Revised 06.07.2005
         Current Academic Status (PLEASE ATTACH COPIES OF ACADEMIC TRANSCRIPTS)
         Current Grade Level:                                                   Grade Point Average (GPA):

         Credits earned toward graduation:                                      Remaining credits required for graduation:

         Is student following a college preparatory curriculum?                 Has the student taken the college entrance examinations
               Yes       No                                                   (ACT/SAT)?
                                                                                         Yes    No

         Learning Differences (PLEASE ATTACH COPIES OF EVALUATIONS, IEP OR OTHER RELATED DOCUMENTS)
         Does student have a preferred learning style (written, oral, graphic visuals, experiential, tactile)?

         Does student have any known learning differences? If yes, specify type and attach copy of evaluation (if available).
               Yes       No
         Has student ever been diagnosed with any attention issues (ADD, ADHD)? If yes, specify type and attach copy of evaluation.
               Yes       No
         Has student ever been prescribed medication to assist with attention difficulties? If yes, specify name of medication.
               Yes       No
         Are there any special needs or educational considerations required for the student? If yes, please explain
               Yes       No
         Does student have an Individualized Education Plan (IEP)?              Date Implemented                 Date last modified
               Yes       No         If yes, please attach copy of IEP

         School Behavior
         DESCRIBE STUDENT’S FEELINGS ABOUT SCHOOL.




         DOES STUDENT HAVE A HISTORY OF SCHOOL BEHAVIOR PROBLEMS? IF YES, PLEASE EXPLAIN.
               Yes       No


         HAS STUDENT EVER BEEN EXPELLED FROM SCHOOL? IF SO, PLEASE EXPLAIN CIRCUMSTANCES.
               Yes       No



         Educational Interests, Accomplishments and Goals
         DESCRIBE STUDENT’S EDUCATIONAL INTERESTS AND ANY SPECIAL ACCOMPLISHMENTS.




         DESCRIBE ANY EXTRA-CURRICULAR ACTIVITIES IN WHICH THE STUDENT HAS PARTICIPATED.




         DESCRIBE YOUR GOALS/HOPES FOR THE STUDENT FOLLOWING COMPLETION OF HIGH SCHOOL.




         Information Provided By
                         Print Name                                  Signature of Parent/Guardian                            Date Signed




F10016                                                                  Packet Page 9                                                      Revised 06.07.2005
         Request for Educational Records
         Student Name (First, Middle, Last)                                      Date of Birth                       Social Security Number


         Street Address                                                          City                                State      Zip




         Dear Registrar,

         The above named student is being enrolled in New Summit Academy of Costa Rica and prior school
         records are needed to assist in academic planning. Please send copies of the following documents to the
         address at the bottom of the page:

                         Verification of dates of enrollment and withdrawal
                         Reason for withdrawal from your school and withdrawal grades
                         Current credit transcript
                         Educational evaluations, achievement test results, special education assessment
                         IEP, if applicable
                         Disciplinary records
                         Health and immunization records
                         Other records relevant to academic planning
                         Graduation requirements for your school

         Please do not send the original academic record as we would like it to remain on file at your school. Thank you for your prompt attention to
         this request.



         Authorization for Release of Information
         The undersigned hereby grant permission to release all available school records for the above named student to the Registrar of
         New Summit Academy of Costa Rica. Permission is granted to release the following records: official transcript of credit; withdrawal
         grades; special education records; IEP; educational assessment results; health records; immunization records; disciplinary reports;
         counseling information and any records pertaining to psychiatric or psychological evaluation of the student.
                          Print Name                      Signature of Parent/Guardian and Student (if age 18+)                 Date Signed




         Please fax a copy to 561-892-3853




F13105                                                                  Packet Page 10                                                        Revised 06.07.2005
      New Summit Academy                                                                                                Medical History, Page 2
        NAME OF STUDENT




         Student Medical History
         NAME OF STUDENT                                                                                              DATE OF BIRTH




         Current Health Status
         CURRENT OR CHRONIC CONDITIONS AFFECTING THE STUDENT (PLEASE BE SPECIFIC)  None Known



         KNOWN ACTIVITY LIMITATIONS (PLEASE BE SPECIFIC)  None Known



         DIETARY REQUIREMENTS              No restrictions       Low salt            Low sugar           OTHER (describe below)




         Allergies           (PLEASE PROVIDE SPECIFIC ALLERGIES, SEVERITY AND TYPE OF REACTION, DATE OF LAST REACTION)
                                            Date of Last      Severity of
                         Allergy                                                             Describe Reaction                        Treatment
                                             Reaction          Reaction




         Current Medications  No prescribed medications at time of enrollment
                               Name of Medication                      Date Started          Dosage/Schedule       Diagnosis/Reason for Medication




         Prior Psychotropic Medications                           No prior psychotropic medications
         LIST ANY PSYCHOTROPIC MEDICATIONS THAT STUDENT HAS TAKEN IN THE PAST BUT IS NO LONGER TAKING.
                               Name of Medication                      Date Stopped          Dosage/Schedule       Diagnosis/Reason for Medication




         Injuries and Hospitalizations
         HAS APPLICANT HAD ANY SERIOUS INJUIRES? IF SO, PLEASE SPECIFY NATURE OF INJURY AND YEAR OF OCCURRENCE.
          Yes              No



         HAS APPLICANT EVER BEEN HOSPITALIZED FOR MEDICAL REASONS? IF SO, PLEASE EXPLAIN REASON AND DATE OF OCCURRENCE.
          Yes              No



Enrollment Application                                                      Packet Page 11                                                        Revised Aug3006
      New Summit Academy                                                                                             Medical History, Page 2
        NAME OF STUDENT




         Diseases/Medical Conditions                   (HAS STUDENT HAD ANY OF THE FOLLOWING?)
         Acne                         Yes  No         Ear infections, frequent     Yes  No   Muscle weakness               Yes  No
         Anemia                       Yes  No         Eating Disorder              Yes  No   Obesity/over weight           Yes  No
         Asthma                       Yes  No         Epilepsy/seizures            Yes  No   Osgood Schlatter              Yes  No
         Bleeding disorder            Yes  No         Frostbite                    Yes  No   Pneumonia                     Yes  No
         Bone condition               Yes  No         Headaches, frequent          Yes  No   Rheumatic Fever               Yes  No
         Cancer                       Yes  No         Hearing loss                 Yes  No   Scarlet Fever                 Yes  No
         Circulation problems         Yes  No         Heart disorder/problem       Yes  No   Scoliosis                     Yes  No
         Colds, frequent              Yes  No         Heart murmur                 Yes  No   Sickle cell trait             Yes  No
         Constipation, frequent       Yes  No         High blood pressure          Yes  No   Sore throats, frequent        Yes  No
         Dermatitis                   Yes  No         HIV positive/AIDS            Yes  No   Syphilis / Gonorrhea          Yes  No
         Diabetes                     Yes  No         Joints, problem with         Yes  No   Urinary Tract Infections      Yes  No
         Diarrhea, frequent           Yes  No         Mononucleosis                Yes  No   Other (Specify below)         Yes  No

         If you answered yes to any items above, please provide additional information.
                                       Date of Last
                 Condition                                                                  Explanation
                                       Occurrence




         Family Medical History              (HAVE ANY OF THE STUDENT’S CLOSEST BIOLOGICAL RELATIVES HAD ANY OF THE FOLLOWING?)
                                                               Family Member                         Please provide details
         Bleeding disorder               Yes  No
         Cancer                          Yes  No
         Cardiovascular disease          Yes  No
         Diabetes                        Yes  No
         Drug/alcohol dependency         Yes  No
         Psychiatric illness             Yes  No
         High blood pressure             Yes  No
         Other (specify)                 Yes  No

         Additional Medical History
         PROVIDE ANY OTHER MEDICAL INFORMATION NOT PREVIOUSLY LISTED AND ANY OTHER IMPORTANT INFORMATION RELATING TO THE HEALTH
         HISTORY OF THE STUDENT.




Enrollment Application                                                 Packet Page 12                                                Revised Aug3006
      New Summit Academy                                                                                             Medical History, Page 3
        NAME OF STUDENT




         Immunizations
         Please provide complete information regarding student’s immunizations. If necessary, consult the student’s physician and/or obtain a copy
         of the student’s immunization records for our files.
                                                               st                nd                rd                  th                 th
                                                              1 Dose           2 Dose             3 Dose              4 Dose             5 Dose
                           Immunization
                                                               (Date)            (Date)            (Date)              (Date)             (Date)
         Diphtheria, Tetanus, Pertussis (DTP)

         Polio

         Measles, Mumps, Rubella (MMR)

         Tetanus, Diphtheria (Td)

         Varicella

         Hepatitis B

         Hepatitis A

         Tuberculosis skin test

         Medical Provider Contact Information
         PHYSICIAN’S NAME (PLEASE PRINT)


         STREET ADDRESS                                                        CITY                                STATE     ZIP


         TELEPHONE                                                             FAX


         E-MAIL                                                                DATE OF LAST EXAMINATION


         DENTIST’S NAME (PLEASE PRINT)                                         STUDENT REQUIRES (CHECK ALL THAT APPLY):

                                                                                       RETAINER            DENTURES
         STREET ADDRESS                                                        CITY                             STATE        ZIP


         TELEPHONE                                                             FAX


         E-MAIL                                                                DATE OF LAST EXAMINATION


         ORTHODONTIST’S NAME (PLEASE PRINT)                                    STUDENT REQUIRES (CHECK ALL THAT APPLY):

                                                                                       RETAINER            BRACES
         STREET ADDRESS                                                        CITY                             STATE       ZIP


         TELEPHONE                                                             FAX


         E-MAIL                                                                DATE OF LAST EXAMINATION


         OPTOMETRIST’S NAME (PLEASE PRINT)                                     STUDENT REQUIRES (CHECK ALL THAT APPLY):

                                                                                       EYEGLASSES          CONTACT LENSES
         STREET ADDRESS                                                        CITY                             STATE     ZIP


         TELEPHONE                                                             FAX


         E-MAIL                                                                DATE OF LAST EXAMINATION



         Information Provided By
         The undersigned hereby attests that the medical information provided above is accurate and complete.
                          Print Name                                Signature of Parent/Guardian                            Date Signed




Enrollment Application                                                Packet Page 13                                                         Revised Aug3006
             Consent to Medical Treatment
              and Insurance Information
NAME OF STUDENT                                                                                        DATE OF BIRTH


The undersigned hereby authorizes and consents to any medical or dental procedure undertaken for the health and well-being of
the above-named Student. This authorization includes, but is not limited to, examinations, x-rays, inoculations, vaccinations,
medical, dental or surgical procedures, administration of local and/or general anesthetics and/or hospital care. The undersigned
understands that the previously described treatment will be rendered only under general or special supervision and upon the advice
of a physician or dentist licensed to practice medicine in the area where the services are rendered. The undersigned also
understand that medical and dental professionals or clinics in Costa Rica may provide treatment. The undersigned further
authorizes New Summit Academy of Costa Rica (hereinafter “the Academy”) to disclose the following insurance information to other
medical/dental providers responsible for the care of the above named student. The undersigned further authorizes the Academy or
other medical/dental providers to disclose medical information needed to submit insurance claims on behalf of the above named
student and authorizes payment to be made directly to the provider submitting the claim. The undersigned understands that any co-
payments, non-covered services and/or over-the-counter medications will be billed directly to the undersigned or other official
financial sponsor designated by the undersigned.
PRINT NAME OF PARENT/GUARDIAN                 SIGNATURE OF PARENT/GUARDIAN                            DATE SIGNED




Medical Insurance (SUBMIT COPY OF FRONT AND BACK OF INSURANCE CARD WITH THIS FORM)
INSURANCE COMPANY (PLEASE PRINT)


STREET ADDRESS                                                       CITY                              STATE    ZIP


INSURANCE PROVIDER TELEPHONE                                         FAX


POLICYHOLDER NAME                                                    POLICY HOLDER’S SOCIAL SECURITY NUMBER


POLICY NUMBER                                                        GROUP NUMBER (IF APPLICABLE)


POLICYHOLDER EMPLOYER (IF GROUP POLICY)


COVERAGE (EMERGENCY, MENTAL HEALTH, PHARMACY, ETC.)


PRESCRIPTION INSURANCE PROVIDER                                      PHARMACY CARD NUMBER              PHARMACY DEDUCTIBLE/CO-PAY



SIGNATURE OF POLICYHOLDER                                                                              DATE SIGNED




Dental Insurance (SUBMIT COPY OF FRONT AND BACK OF INSURANCE CARD WITH THIS FORM)
INSURANCE COMPANY (PLEASE PRINT)


STREET ADDRESS                                                       CITY                              STATE    ZIP


INSURANCE PROVIDER TELEPHONE                                         FAX


POLICYHOLDER NAME                                                    POLICY HOLDER’S SOCIAL SECURITY NUMBER


POLICY NUMBER                                                        GROUP NUMBER (IF APPLICABLE)


POLICYHOLDER EMPLOYER (IF GROUP POLICY)


COVERAGE (EMERGENCY, PREVENTATIVE, COSMETIC, ETC.



SIGNATURE OF POLICYHOLDER                                                                              DATE SIGNED



                                                            Packet Page 14                                              Revised 06.07.2005
Travel and Transportation Arrangements
Student Name (First, Middle, Last)                                                                          Date of Enrollment




Parents should review the enrollment instructions prior to making any travel arrangements. Airline reservations should not be paid for until
reviewed and approved by the Admissions Office.


Airline Reservations
Arrival Information
        Date                 Airline           Flight No.        Departure City      Departure Time        Arrival City          Arrival Time

                                                                                              AM/PM                                      AM/PM

                                                                                              AM/PM                                      AM/PM

                                                                                              AM/PM                                      AM/PM



Departure Information                   One-way ticket purchased             Return ticket can be rescheduled without penalty
        Date                 Airline           Flight No.        Departure City      Departure Time        Arrival City          Arrival Time

                                                                                              AM/PM                                      AM/PM

                                                                                              AM/PM                                      AM/PM

                                                                                              AM/PM                                      AM/PM



Transportation from Airport
      Student will be traveling with a parent or guardian who will rent a car at the airport and drive to
       the program.
      Student will be traveling with [insert number] _____ parent(s) or guardian(s) and all parties will
       require transportation from the airport to the school.
      Student will be traveling unaccompanied and will need transportation from the airport.

Authorization and Consent for Transportation
The undersigned hereby authorizes New Summit Academy of Costa Rica personnel to meet above-
named Student at the airport and transport Student in a program motor vehicle to the program site in
Atenas, Alejuela, Costa Rica for enrollment in the program. Cost of these services is $___________ and
will be charged to Student’s Expense Account. A picture of the Student will be provided to assist in
identifying the Student at the airport.

                     Print Name                                   Signature of Parent/Guardian                            Date Signed




                                                               Packet Page 15                                                    Revised 06.07.2005
   Student Visa / Immigration Information
Student Name (First, Middle, Last)                                                                          Date of Enrollment




Students traveling with a USA passport can be in Costa Rica as a “tourist” for 90 days before needing to leave the country. In order to apply
for a student visa, we need the following information and documentation. Please note that the sooner these documents are acquired, the
easier it will be to get a student visa for your son.


Parent / Guardian Information
This is the information needed to prepare the legal documents for the student visa.
                                                                                                                                      Civil Status
   Parent / Guardian         First Name, Middle Name, Last Name                    Address                  Passport #
                                                                                                                                  (mark all that apply)

                                                                                                                                 SINGLE / WIDOWED
 Guardian #1                                                                                                                     DIVORCED __ TIMES
                                                                                                                                 MARRIED __ TIMES

                                                                                                                                 SINGLE / WIDOWED
 Guardian #2                                                                                                                     DIVORCED __ TIMES
                                                                                                                                 MARRIED __ TIMES

                                                                                                                                 SINGLE / WIDOWED
 Other                                                                                                                           DIVORCED __ TIMES
                                                                                                                                 MARRIED __ TIMES


Documentation Required
      BIRTH CERTIFICATE: Your son will need a birth certificate certified by the Costa Rican
       consulate in the United States. The easiest way to do this without having to travel to a consulate
       in your son’s birth state is to:
                 o     Get a birth certificate from the originating courthouse.
                 o     The Costa Rican consulate in Washington, D.C., will attend requests from all over the
                       USA. Call the consulate during business hours (10am-1pm ET) to make sure that they
                       will attend to your request for certification via mail.
                                    Consulate of Costa Rica in Washington D.C.
                                     2112 "S" Street N.W., Washington, DC, 20008 USA
                                     Tel: 202- 328-6628     Fax: 202-234-6950
                                     Contact: Mr. Alejandro Cendeño, Consul General
                 o     Send the certificate with a note instructing certification via DHL or FedEx to the consulate
                       in Washington, D.C. (along with a prepaid return FedEx or DHL envelope).
                 o     Once returned, FedEx or DHL the birth certificate to NSA at:
                       M. Duran / Quinta Dorovanci
                       1 km Este del Monumento Boyero,
                       Los Angeles de Atenas, Alajuela, Costa Rica
      POWER OF ATTORNEY: Costa Rican child welfare laws require that any minors in Costa Rica
       without their legal guardians must have a legal guardian who can act on their behalf in case of
       legal or medical emergency. Our lawyer has documents (in Spanish) ready for you to sign when
       you bring your son to NSA. If you would like a copy of this document (in either Spanish or
       English) to review before you sign, please let us know.


                                                                  Packet Page 16                                                 Revised 06.07.2005
                Medication / Psychiatric Supervision
         Student Name (First, Middle, Last)                                                    Date of Enrollment




         NSA is not a medical facility, a rehabilitation center, or a school with many psychiatric needs. However,
         some students may be taking medication for anxiety, depression, or attention deficits. Students who are
         taking any kind of medication need to be monitored by a doctor. Dr. Steven Kogel provides these services at
         an extra cost for NSA students. In general, Dr. Kogel meets with students twice a month to monitor
         medication and other needs, including substance abuse recovery.

         Agreement for Services of Dr. Steven Kogel

         I agree that my son, _____________________________________________, has my
         permission to meet with Dr. Steven Kogel approximately twice a month (or as needed)
         with the objectives of monitoring his medication, to provide outside therapy, or to
         provide psychiatric assessment in case of a therapeutic crisis. I also agree to be
         charged $100 per 45-60 minute session with Dr. Kogel in order that these objectives
         may be completed.


         Guardian #1 Name (Printed): _______________________________________________________________________________


         Guardian #1 Signature: __________________________________________________ Date signed: _______________________




         Guardian #2 Name (Printed): _______________________________________________________________________________


         Guardian #2 Signature: __________________________________________________ Date signed: _______________________




Enrollment Application                                     Packet Page 17                                           Revised Aug3006
Enrollment Checklist
Congratulations!!            You have now completed the Enrollment Application. Using this
Enrollment Checklist as a guide, collect all required supporting documents. Then submit the
completed application, this checklist and all required supporting documents to the Admissions
Office. If for any reason all documents listed on the checklist will not be submitted at the same
time, please include an explanation including when the missing documents may be expected.

Student’s Name:                                                    Date Submitted:


    Enrollment Application completed and each section authorized by:
             Custodial parent only if custody is not shared and one parent has full custody.
             Both parents if custody is shared.
             Applicant if age 18 or over.
             Applicant is at a different location than the parent(s) and will need to sign these
              documents following enrollment.

    Provide copies of all psychological, psychiatric and/or educational evaluations that have
     been conducted.

    Student Questionnaire is being:
           Submitted with Enrollment Application,
           Completed separately and submitted by student
           Sent separately to student to complete and return to the Admissions Office
    Educational Records - The Request for Educational Records form has been submitted to
     each high school the student attended. The student’s educational records are:
          Enclosed with this packet.
          Being sent directly to the New Summit Academy Admissions Office by each school.
          New Summit Academy Admissions Office should expect to receive educational
             records from ____ different schools.
    Physical Examination conducted within the last 90 days, as follows:
             New physical examination conducted and documented on New Summit Academy
              Physical Examination form.
             Copy of recent physical examination conducted for or by wilderness program sent to
              Admissions office; includes activity clearance.
             Copy of recent physical examination conducted for or by wilderness program; does
              not include activity clearance.
             Activity clearance form signed by primary care physician and submitted to
              Admissions Office.
             Additional laboratory tests are required.
    Status of student’s immunizations is as follows:
             Childhood immunizations are current
             CDC recommended vaccinations for travelers to Central America have been
              administered
             CDC recommended vaccinations for travelers to Central America need to be
              administered upon the student’s arrival in Costa Rica




                                                Packet Page 18                                      Revised 06.07.2005
         New Summit Academy                                                  Enrollment Checklist, Page 2

            Completed Consent to Medical Treatment and Insurance Information form submitted to the
             Admission Office with the following attachments:
                  Copy of front and back of medical insurance card
                  Copy of front and back of pharmacy card
                  Copy of front and back of dental insurance card
            Medication – 60 day supply of each prescribed medication will be:
                  Placed in student’s carry-on baggage
                  Placed in student’s checked baggage
            Completed Enrollment Agreement signed appropriately as indicated below and submitted to
             Admissions Office
                    Signed appropriately as follows:
                    One custodial parent only if custody is not shared and one parent has full custody
                    Both parents if custody is shared
                    Student if age 18 or over
                    Financial Sponsor if party other than the parents or legal guardian is responsible for
                     payment of tuition and ancillary fees.
            Copy of Student’s Passport submitted to Admissions Office
                  Student has a current passport that will not expire within one year of the student’s
                     enrollment.
                  Student has a passport but it will expire in less than one year; a passport renewal
                     application has been submitted.
                  Copy of inside cover of student passport is attached (page containing student’s
                     name, picture, Passport Number, Date of Issue and Date of Expiration).
                  Passport photos – four extra copies to be used in applying for Student Visa.
            Travel Arrangements (see Pre-enrollment Requirements Instructions)
                  Travel arrangements have been made following review by admissions counselor.
                  Travel and Transportation form completed and submitted to Admissions Office.
                  Flight itinerary has been emailed or faxed to Admissions Office.
            Sign Agreement for Psychiatric Services / Medication Monitoring by Dr. Kogel
            Student Visa / Immigration Documents
                  Guardian information has been submitted to Admissions Office.
                  Birth Certificate has been certified by the Costa Rican consulate.
                  Signing of the Power of Attorney documents are planned for the day of enrollment.
         Comments:




F10021                                            Packet Page 19                                       Revised 01 May 2006

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:9
posted:11/13/2011
language:English
pages:19