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Lummi Nation Employment Application Form - PDF by gjl53109


Lummi Nation Employment Application Form document sample

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									  Summer School                  Kids 1st                     Other______________

     Summer School Application
This Application Belongs To:                           Date:_______________

                          Please print full name of child

School Attended___________                         Grade Completed_______

                                 Please make sure you
                                 have the following for
                                 each child:
                                    □CIB or Enrollment
       2009                      Kids First (High School):
 Please ONE                         □CIB or Enrollment
 Application                        □Official Transcripts
                                    □ID Card
  Per Child
                                    □Social Security Card
 Thank You!
                                 Office Use Only

Reviewed By:___________________________                     Date _________________

Needs To Complete:_________________________________________________________
Approved By:______________________________________________________________

                                                            Application Complete
Lummi Nation K-12 School/YESS/Kids 1st /Day                                    STUDENT REGISTRATION
Camp/High School Summer Program                                                SUMMER SCHOOL APPLICATION
Names of Students Applying: Please use legal Name                                                Grade Completed               Social Security #:
Last Name                          First Name            MI                       Age            as of June 2009:

1.) ______________________________________________________________________                       Child 1__________             Child 1______________

Mailing Address:                                     Home #                         Cell #                  Message #

Student Birth Date         Gender                    Birthplace:       City             State            County
Child 1__________          Child 1__________         Child 1___________________________________________

Is Your Child Enrolled in a Federally Recognized Tribe?                                                               Tribal Enrollment No:
If yes, Name of Tribe:
1.) ______________________________________________________________________                      yes        no         Child 1_______________

Student Lives With:    Both Parents    Father Only       Mother Only           Grandparents     Father/Stepmother             Mother/Stepfather
                       Stepfather/Stepmother             Guardian              Self             Agency                        Other ________________

Parent/Guardian Name                       Address                                                    Home Phone Number           Work/Message Number

Parent/Guardian Name                       Address (if different than above)                          Home Phone (if              Work/Message Number
                                                                                                      different than above)

Emergency Contact Person #1                Address                                                    Home Phone Number           Work/Message Number

Emergency Contact Person #2                Address                                                    Home Phone Number           Work/Message Number

Please List any Medical Conditions:        Currently on any Medications?                              Special Diet? Be specific:
Child Name _________________________       Child Name __________________________                      Child Name: __________________________
Condition ___________________________      Medication___________________________                      Dietary Needs:_________________________

E     In the event I/We cannot be contacted, I/We, the undersigned parent or legal guardian of,           Chronic Illnesses?
      Child 1_________________________ hereby consent and give permission to the Lummi
M     Nation YESS Department and Lummi Nation School Summer High School Program,                          Child Name:________________________
E     Kids First, and Day Camp to render and authorize emergency medical treatment,
R     including hospitalization and medical procedures deemed necessary by a physician.                   Illness:_____________________________
G     If I cannot be reached please contact:
N     Name:_______________________ Relationship to Child:_____________________
C     Contact #____________________
Y     Name:_______________________ Relationship to Child:_____________________
      Contact #____________________
      Name:_______________________ Relationship to Child:_____________________
      Contact #____________________
I     Date of Last Tetanus Booster: (Please list all children)
C     ________________________________________________________________________
A     ________________________________________________________________________
      Primary Physician:___________________________ Contact #________________
      By this document, I hereby release the Lummi Nation School, the YESS Department, its
E     employees, and volunteers from any and all liability, claims, and/or causes of action
L     arising out of, or in any way relating to the provision of necessary medical treatment for
      Parent/Guardian Signature:_____________________________________________
S     Date:______________________
Previous School(s) Attended                          Address                                              Phone Number               Fax Number
Child Name/School Attended:                          ______________________________________               ________________           _______________
_________________________________                    ______________________________________                _______________           _______________
_________________________________                    ______________________________________               ________________           _______________
_________________________________                    ______________________________________               ________________           _______________
_________________________________                    ______________________________________               ________________           _______________

Any Court Orders in Effect?           yes      no                             Has Your Child (ren) Ever Been Retained?
(If yes, please attach a copy of the court order.)                                yes     no
                                                                              If yes, Please list name and Grade Retained?

Does your child(ren) have a current Individual Education Plan (IEP)?                 yes        no (If Yes please list names)

Photograph Information     Yes, my child (ren) may be photographed/video for school purposes only.   No, my child (ren) may not be photographed.

                                                  FIELD TRIP RELEASE

I hereby authorize my Child(ren), Child 1___________________________, to participate in the scheduled afternoon field trips
provided by Lummi Nation School, the YESS Department, Kids First, Day Camp and the Summer High School Program.

______________________________________________________                                     _____________________________
Parent/Guardian Signature                                                                   Date
                                                    Transcript Release

                                                      REQUEST FOR TRANSFER
                                        OF OFFICIAL TRANSCRIPTS and/or ATTENDANCE REPORTS
TO:                                                                                                       _________________
                 (Please list program(s) in which you child(ren) are participating)

Attn:             Registrar___________

Child Name:_______________________               SSN:___________________              DOB:_____________

         I hereby give my permission to the above named programs to forward all official transcripts and/or attendance records to the Lummi
Nation School Summer School Programs. I understand that photocopies of these documents will be provided to the summer school programs
when needed, and I will hold harmless my previous school district for this transfer of records.

Student Signature:________________________________________________________ Date:__________________________
(If over 18 years of age)
Parent /Guardian Signature                                                 Date
(If under 18 years of age)


Program Requesting Information:

Program Name:_____________________________________________                            Address:____________________________
                                                                                      Fax:    ____________________________

Program Managers Signature:__________________________________                          Date:   ___________________________

I certify that the above information provided is true to the best of my knowledge. I am also aware that the information is
subject to verification and that falsification of the application shall be grounds for termination from the program. I
understand that I have to provide documents to support this application.
Participant Signature:                                                                    Date:
(If applying for Kids 1st Employment)
Child 1___________________________________________________________________

Parent/Guardian Signature:                                                                       Date:

Staff Signature:                                                                                 Date:

                                SUMMER SCHOOL 2009
      Lummi Nation K-12 School/YESS/Kids 1st / Day Camp/High School Summer Program

                            Ethics & Code of Conduct Policy
    1. The possession, use and/or consumption of alcohol, tobacco or illegal drugs are not
        allowed during any sponsored program or activity.
    2. The program will not tolerate any form of physical or verbal abuse on the part of the
        program participates or instructors. This includes any markings (i.e. hickies or offensive
    3. The program will encourage participants to respect” Personal Space” of self and others.
        Zero tolerance of inappropriate behaviors is cause for expulsion of individual offenders.
    4. The program will not tolerate possession of weapons of any sort.
    5. The program will enforce a dress code. Appropriate attire is required for participants.
        Cleanliness and neat appearance is expected of all participants and instructors.
    6. The program will not tolerate the wearing of “colors”. Bandannas may only be worn by
        those who are required to do so for cultural reasons.
    7. ATTENDANCE: you are required to be in class everyday in order to receive your
        stipend for that work. Attendance sheets are reviewed weekly and approved by
        Instructors on Fridays. This is Non-Negotiable. In Addition, attendance is monitored
        regularly by Kids First Staff. Falsification of attendance is grounds for immediate
    8. JOB PLACEMENT: participants of the Kids 1st Program who will be receiving a
        stipend will be required to fulfill job duties as assigned by supervisor, will be required to
        complete the full work day as outlined by supervisor and will be expected to keep a daily
        log of duties completed and signed off by supervisor daily. (Logs will be provided)
        Falsification of daily logs and timekeeping records will be grounds for immediate
Failure to comply with any of the above non-negotiable policies will be cause for immediate
suspension from the program. If you are suspended form the program you will not receive your
stipend until the completion of the summer school program.

I have read the above policies and understand my responsibility to fellow participants, the Kids
First Program and I will abide by these policies while participating in the Summer School
_____________________________________________                ______________________
Signature of Participant                                     Date

_____________________________________________                 ______________________
Parent/Guardian Signature                                     Date

                                  SUMMER SCHOOL 2009

        Lummi Nation K-12 School/YESS/Kids 1st /Day Camp/High School Summer Program

                       DRUG & ALCOHOL POLICY CONTRACT

I agree to follow the Summer School Program Drug & Alcohol Free Policy while
participating in the Summer School Program, by adhering to the following Policies:

Please have all
participants initial

__ __ __ __ __ 1.) To abstain from Drugs & Alcohol during my employment

__ __ __ __ __ 2.) I understand that the Summer School Program is to support and promote
                   my effort in making healthy choices.

__ __ __ __ __ 3.) I will not expose myself to unsafe environments and lifestyles.

__ __ __ __ __ 4.) I understand the “Zero Tolerance” of the Summer School Program and will
                   abide by this policy. Random UA’s may be utilized to ensure the
                   integrity of this program

__ __ __ __ __ 5.) I also agree to talk to staff if I am having problems with substance abuse
                    to set up a plan of assistance to be successful.

I am fully aware of the support and opportunity the Lummi Nation collaborating programs are
giving me to obtain the skills needed to enter into the workforce and further my education.

_____________________________________________             ______________________
Signature of Participant                                  Date

_____________________________________________             ______________________
Parent/Guardian Signature                                 Date

                                            LUMMI NATION YESS DEPARTMENT
                                         INFORMED CONSENT FOR A CHILD/YOUTH

   PURPOSE: The YESS department provides strength-based counseling, and physical therapy (PT) at both Lummi
   Nation School and Lummi Head Start; occupational therapy (OT) and speech therapy at Lummi Head Start. The
   focus is on: communication, coping skills, identifying and expressing feelings, problem-solving skills, social-
   emotional and self-esteem development. The student will be provided with services as needed.

   SERVICES AND STAFF: A qualified Mental Health Professional/Counselor provides strength-based counseling
   through a holistic approach with individuals and small group activities in a classroom setting. The Lummi Nation
   YESS Department will keep the records of this treatment in a YESS Clinical Chart that is safeguarded in our
   Administrative Office. We work as a team in order to provide the best care for your child. Qualified, contracted
   professional specialists provide OT, PT and speech therapy. Our team members include Head Start, Lummi Nation
   School, Lummi Youth Academy, Lummi CARE, and the Lummi Tribal Health Center. However, confidential
   information from counseling sessions will only be shared with your written permission.

   CONFIDENTIALITY: All information disclosed within a therapeutic activity is confidential and may not be
   revealed to anyone outside the YESS Department clinical program without your written consent. Notice of Privacy
   Practices is strictly adhered to according to HIPAA regulations. The only exception is in situations where disclosure
   is required by law:
     1. If a child/youth presents with imminent danger to himself/herself   3. If a child/youth becomes gravely
     or others;                                                             disabled, and
     2. When there is an indication of abuse of a child or dependent adult; 4. By court subpoena.

   ELIGIBILITY AND COST: The YESS Department will bill Medicaid for services. However, all Lummi
   children/youth are eligible for this service whether they have an active Medicaid coupon or not. Medicaid funds
   allow Lummi Nation to expand and enhance the quality of services for all children. If you would like to find out
   how to apply for Medicaid assistance for your child, please call the office at (360) 384-2373.

   This form documents that you agree to have your child receive services, per required need, through the Lummi
   YESS Department. It also records whether or not you agree to have information shared as needed with Head Start,
   Lummi Nation School staff, Lummi Youth Academy, Lummi CARE and the Lummi Tribal Health Center.

→   I give my permission for (child/youth’s name) ________________________ to receive at: Lummi Nation School, Lummi Youth Academy, or
   Head Start, mental health/counseling services and, as needed, occupational therapy, physical therapy and speech therapy, from YESS Department
   Mental Health Professional staff or YESS Department contracted Professional Specialists. I understand that the YESS Administrative Office
   Quality Assurance team will monitor the records for these services.

   I understand that unless I choose the ‘no confidential information be shared’ preference below, that I also give my permission for the YESS
   Department Professionals to share confidential information regarding my child with Head Start, Lummi Youth Academy, and /or Lummi Nation
   School staff as needed, to assist in my child’s development and learning experience.

   ( ) I prefer that no confidential information be shared with Lummi Head Start or Lummi Nation School staff.


   Parent/Guardian’s Name (Print): ________________________________________ Child’s DOB: ___________

   Child’s Name (full legal name with middle initial): _______________________________SSN: __________________

   Relationship to Child (Please circle): Mother          Father      Aunt       Uncle     Grandmother Grandfather            Other

   If ‘Other’ please explain: ______________________________Your Phone Number: ______________________

   Your Address: ______________________________________________________________________________

   Emergency Contact: _________________________________ Contact Phone Number: ___________________

→Custodial Parent/Legal Guardian/Youth Signature _________________________Date ________________

   Staff signature: ________________________________________________________Date ________________

The YESS Department is responsible for providing information to clarify the mutual
responsibility for service delivery to your child/youth.

By signing this document, you acknowledge receipt of the YESS Client Handbook or the
Summer Program Application Packet, which includes (when applicable):

  Client’s Rights       Notice of Privacy Practices         Consent for Services
  Disclosure            Permission Slips                    Emergency Medical Release Forms
  Ethics Code           Behavior Contract                   Release of Information

______________________________________                    ________________________
Signature                                                 Date

Print Name

Name of Child


                                   PRIVACY PRACTICES

My signature below confirms that I have been informed of my rights to privacy regarding my
protected health information, under the Health Insurance Portability and Accountability Act of
1996 (HIPAA). I understand that this information can and will be used to:
       Provide and coordinate my treatment among a number of health care providers who may
       be involved in that treatment directly and indirectly
       Obtain payment from third party payers for my health care services
       Conduct normal health care operations such as quality assessment and improvement

I have been informed of my Social Service provider’s Notice of Privacy Practices containing a
more complete description of the uses and disclosures of my protected health information. I
have been given the right to review and receive a copy of such Notice of Privacy Practices and
that I may contact this office at the address above to obtain a current copy of the Notice of
Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or
disclosed to carry out treatment, payment or health care operations and I understand that you are
not required to agree to my requested restrictions, but if you do agree then you are bound to
abide by such restrictions.

Client/Student Name: ____________________________ Date: __________________

Signature: ______________________________________________________________

Relationship to Client/Student: ______________________________________________

                                         LUMMI NATION
                                      YESS DEPARTMENT
                                  DISCLOSURE STATEMENT
State law requires that all counselors that provide services for a fee to register with the
Department of Health for the protection of the public health and safety. Registration of an
individual with the Department does not include recognition of any standards of practice. Nor
does it imply effective treatment. The following information is required to be provided to all
Treatment Philosophy: A strength-based counseling program is provided by a qualified Mental
Health Professional/Counselor through a holistic approach that provides individual and small
group activities in a classroom setting. Lummi Nation youth have been exposed to ecosystems
deprived of proper development due to: cultural genocide, poverty, the destruction of the
traditional Coast Salish way of life, drugs and alcohol, lack of employment opportunities, and a
history of trauma and loss. We are focused on providing Lummi Nation youth with support and
problem-solving skills to combat the ramifications of invasion utilizing the inherent strengths of
the Nation: being family oriented, being a resourceful people resilient to oppression, strife, and
adverse situations on a personal, community, and global basis, and knowing where they come
from and who they are as a people.
Fees: The YESS Department will bill Medicaid or other insurance for services. A lack of
personal financial resources will not prevent Lummi Nation youth from receiving counseling
Counselor Education and Training: All counseling staff must meet the credential requirements
as set forth in all applicable Washington Administrative Codes (WAC’s). Our Quality
Assurance program regularly inspects counselor credentials in order to verify that counselors
continue to meet requirements. Other program staff is licensed in accordance with a variety of
state requirements and is required to maintain current licenses and certificates.

                NAME                                       JOB TITLE                           REGISTRATION NUMBER
Julia Ortiz, MSW, LMHC                       Technical Support/Mental Health               LH00011069
Carmen Fitzgibbon MA. Ed.                    Mental Health Professional                    RC00047149
Sharon Grier MFT                             Mental Health Professional
Shaleena Bertram MSW                         Mental Health Professional                    RC00052940
Miranda Keefe MS                             Mental Health Professional                    RC00052586
John Plummer Ph. D., LMHC                    Mental Health Professional                    LH00004451
Lori Goulet MA                               Mental Health Professional                    RC00051165
Jennifer Tietz, MA                           Mental Health Professional                    RC00044600
Felicia Molano, MA, LMHC                     Mental Health Professional                    LH00011036
Russ Hardison, MA, LMHC                      Mental Health Professional                    LH00007994
Michelle McNeal, Ph.D.                       Physical Therapist                            PT00009922
Teresa Allison, MA                           Occupational Therapist                        OT00004157
Navneet Zyon, MA                             Speech & Language                             LL00003572

During the course of treatment youth may receive counseling and other program services from any or all of the professionals listed on the
Counselor Authentication Form, which is located in the file and has their registration numbers.
Discipline: Counselors are subject to discipline by the Department of Licensing. Cause for disciplinary action for unprofessional
conduct is found in RCW 18.130.180 and includes the following:
     •    False, fraudulent or misleading advertising
     •    The commission of any act involving moral turpitude, dishonesty or corruption relating to the practice of counseling
     •    Incompetence, negligence or malpractice resulting in injury or unreasonable risk of harm to patient/client
     •    Continuing to practice when a certification or registration has been suspended, revoked or restricted by the Secretary of
          the Department of Health

Client Signature: _____________________ Date: _________________________

                                       LUMMI NATION
                                      YESS DEPARTMENT
                                       CLIENT RIGHTS
You have the right to:
   1. Be treated with respect, dignity, and privacy.
   2. Develop a plan of care and services, which meets your unique needs.
   3. The services of a certified language or sign interpreter and written materials and alternate
       format to accommodate disability consistent with Title IV of the Civil Rights Act.
   4. Refuse any proposed treatment, consistent with the requirements in chapter 71.05 and
       71.34 RCW.
   5. Receive care, which does not discriminate against you, and is sensitive to your gender,
       race, national origin, language, age, disability, and sexual orientation.
   6. Be free of any sexual exploitation or harassment.
   7. Review your clinical record and be given an opportunity to make amendments or
   8. Receive an explanation of all medications prescribed (if applicable), including expected
       effect and possible side effects.
   9. Confidentiality, as described in chapters 70.02, 71.05, and 71.34 RCW and regulations.
   10. All research concerning consumers whose cost of care is publicly funded must be done in
       accordance with all applicable laws, including DSHS rules on the protection of human
       research subjects as specified in chapter 388-04-WAC.
   11. Make an advance directive, stating your choices and preferences regarding your physical
       and mental health treatment if you are unable to make informed decisions.
   12. Appeal any denial, termination, suspension, or reduction of services and to continue to
       receive services at least until your appeal is heard by a fair hearing judge.
   13. If you are Medicaid eligible, receive all services, which are medically necessary to meet
       your care needs. In the event that there is a disagreement, you have the right to a second
       opinion from a provider within Lummi Indian Business Council, the Office of Tribal
       Liaison for Medicaid and Medicare services about what services are medically necessary.
   14. Lodge a complaint with the provider and/or the Lummi Indian Business Council if you
       believe your rights have been violated. If you lodge a complaint or grievance, you must
       be free of any act of retaliation. At your request you can receive assistance in filing a
       grievance through the Lummi Indian Business Council.
   15. Report immoral and illegal behavior by a therapist.
   16. Ask for and get information about the therapist’s qualifications (counselor disclosure),
       including his or her license, education, training, experience, membership in professional
       groups, special areas of practice, and limits on practice.
   17. Have written information, before entering therapy about fees, method of payment,
       insurance coverage, number of sessions the therapist thinks will be needed, substitute
       therapists (in cases of vacation and emergencies), and cancellation policies.
   18. Refuse audio or visual recording of sessions (but you may ask for it if you wish).
   19. Refuse to answer any question or give any information you choose not to answer or give.
   20. Know if your therapist will discuss your case with others (supervisors, consultants, or
       students). Ask the therapist to inform you of your progress.
   21. The right of religious accommodation while in treatment. and
   22. Have family members participate in care decisions when appropriate.
I have read or had the above rights read to me and understand that by signing below I indicate that my rights have
been clearly explained to me.
________________________________             ____________________________________
Signature                                    Date
_____________________________ ______________________________
Witness                                      Date
                                        K to 12th Grades
                                           Field Trip
                                        Permission Form

I/We, the undersigned parent or legal guardian of ___________________________(my child),
hereby consent and give permission to the Lummi Nation YESS Department in conjunction with
the Lummi Head Start, Lummi Nation Schools, Lummi Youth Recreation Program and the
Lummi Youth Outreach Program and/or all involved programs, for my child to participate in
planned afternoon field trips and/or on-site enrichment and field activities for the academic
school year of 2009-2010.

I hereby release and save harmless the Lummi YESS Department in conjunction with above
named Lummi Nation programs, staff and/or all involved programs – free from any and all harm
arising to my child as a result of these field trips and/or on-site enrichment and field activities.

Parent or Legal Guardian Signature  Date              Phone Number

First Emergency Contact Name                          Phone Number

Second Emergency Contact Name                         Phone Number

Child’s Physician                                     Phone Number

Medical conditions/Allergies/Medications and Use

Date of Last Tetanus Booster

DATE OF ACTIVITY/EVENT: ____________________________________________

                                      K to 12th Grades
                               Emergency Medical Release Form

In the event I/We cannot be contacted, I/We, the undersigned parent or legal guardian of
__________________________________, hereby consent and give permission to the Lummi
Nation YESS Department to render and authorize emergency medical treatment, including
hospitalization and medical procedures deemed necessary by a physician, to

By this document, I hereby release the Lummi Nation YESS Department, its employees, and
volunteers from any and all liability, claims, and/or causes of action arising out of, or in any way
relating to the provision of necessary medical treatment for

Parent or Guardian Signature                    Date
Date of Birth                                   Home Phone
Known Allergies (including drug reaction)
Special Diet (be specific)
Chronic Illnesses
Medications in Use
Child’s Physician                               Phone Number
Medical Insurance Provider
Subscriber’s Name                               Policy Number


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