1 Student Personal & Medical Information CONSENT TO TREAT Name: Age: Birth : Address: Social Security Number: Grade: Parental/Guardian Information 1. Father/Guardian Name: Birth : Preferred Phone Numbers: Social Security Number: 2. Mother/Guardian Name: Birth : Preferred Phone Numbers: Social Security Number: Emergency Contact Name & Number: Allergies: No allergies Prescription & Non-Prescription Medication Use: No Yes; List: Significant Medical/Surgical History: None Hearing Glasses/Contacts Speech Mental Health History: Depression Suicide Attempt(s): None Counseling Self Harm Eating Disorder: Medical Consent for Treatment: During the school year; Ozark Adventist Academy Staff are given permission to seek medical care/mental health counseling as deemed appropriate for my child, the above named student, in lieu of parental/legal guardian presence. I consent to the release of such information or findings of such care to Ozark Adventist Academy. If emergency treatment is required and a parent/legal guardian cannot be reached for consent, I hereby consent to the provision of emergency care for my child, as necessary, according to the medical opinion of the medical provider rendering the service. In addition, Ozark Academy s school nurse/nurse practitioner is authorized to treat my child as necessary with permission to delegate the administration of non-prescription and prescription medications, as deemed necessary to Ozark Staff, who have been trained accordingly. This consent expires on the last day of school for the year:. Notarized Parent/Guardian Signature State of County of On this day of, 20, before me,, the undersigned notary, personally appeared known to me (or satisfactorily proven) to be the person whose name(s) is/are subscribed to the within instrument and acknowledged that he/she/they executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal. Signature of Notary [Seal of Office] My Commission Expires:
2 PHYSICIAN S EXAMINATION* Student s Name Are Immunizations Current? Yes or No (Please see chart on reverse.) Height Weight Blood Pressure Normal Abnormal Not Examined Explain Abnormalities Skin Eyes, vision, glasses Ears, hearing Nose and throat Mouth, teeth, speech Glands Chest, lungs Cardiovascular, heart Abdomen, enlargement tenderness hernia Spine, back Scoliosis Posture Extremities Nervous System, reflexes Nutritional Status and general appearance of the child Recommendations for additional medical or dental care This student may participate in a normal physical education program which includes such activities as running, jumping, tumbling. Yes No If student must be restricted from participating in activities such as are listed above, please indicate physical activities that may be permitted. Physician s Signature Address *To be completed by the family physician and kept on file at the school for all children, a) entering school for the first time, b) at grade seven (this should include the scoliosis examination), c) at least once in grades nine through twelve, and d) at other grades, when required by the Conference Board of Education.
3 Fax Dawn Hill East Rd., Gentry, AR OZARK ADVENTIST ACADEMY Consent for Release of Information Student Name: I, (parent/guardian), give permission to Ozark Adventist Academy to use and/or disclose my child s medical records and/or immunization records, to healthcare facilities, for the purpose of seeking medical treatment for my child and when deemed necessary, to the Arkansas Board of Health Regulations. I also grant permission to share immunization records, when formally requested, with other educational institutions. This authorization is in effect for the period of time my child is/was enrolled at Ozark Adventist Academy, and as it relates to the purpose of this use or disclosure. If the person or entity receiving this information is not a health care provider or the Arkansas Board of Health or a formal written requested entity as deemed by federal privacy regulations, the information described above is no longer protected by these regulations. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or rendered applicable services. You may inspect or copy your child s health information to be used or disclosed under this authorization. You may revoke this authorization in writing at any time by sending written notification to Ozark Adventist Academy. Your notice will not apply to actions taken by the requesting person/entity prior to the date they receive your written request to revoke authorization. Signature of Parent/Guardian/Student Where students come to discover a love for God, respect for self, and skills for fulfilled Christian living.
4 Fax Dawn Hill East Rd., Gentry, AR History of Varicella (Chickenpox) Illness Disclosure Form The Arkansas Department of Health requires that all students with a history of actual chicken pox (varicella) disease provide supportive formal documentation indicating such through a written statement from a physician or the student s parent/guardian. If your child has had actual chicken pox disease, please complete the following statement below indicating that your child has had chicken pox disease. This is to verify that had varicella disease (Student Name) also referred to as chicken pox during the year of and does not need an initial or secondary varicella vaccine. (Physician/Parent/Guardian Signature) () For further information: Contact the Arkansas Department of Health or visit the Arkansas Department of Health website for additional information. Where students come to discover a love for God, respect for self, and skills for fulfilled Christian living.
5 Fax Dawn Hill East Rd., Gentry, AR Ozark Adventist Academy Consent and Disclosure to Participate in Gymnastics Student Name: At all times, the safety and well being of your child is of the utmost importance at Ozark Adventist Academy (OAA). With this as our foundation, fundamental gymnastic safety instructions will be provided before allowing any student to participate in any gym maneuvers, however; the risk of injury from activity in gymnastics is significant, including potential for injury, permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce the risk of serious injury it does still exist. I grant permission for my child to participate in gymnastic programs with knowledge, appreciation and agreement of the following statements below: I knowingly and freely assume full responsibility for my child s participation; and I willingly consent for my child s participation in the OAA gymnastic program. If however, I observe any unusual significant hazard during my child s presence or participation, I will remove him/her from participation and bring such to the attention of the coach(s) immediately. This is to certify that I, as the parent/guardian with legal responsibility for this participant, to consent and agree to his/her release as provided from any and all liabilities incident to my minor child s involvement or participation in these programs as provided above. Such release is limited only to events that are not directly related to negligent practices that subject my child to injury, harm, or permanent death or disabilities. X Parent/Legal Guardian Signature Where students come to discover a love for God, respect for self, and skills for fulfilled Christian living.
6 Fax Dawn Hill East Rd., Gentry, AR Ozark Adventist Academy Request and Consent for Seasonal Influenza Vaccinations After reviewing the educational information sheet from the Centers for Disease Control (CDC) on the Influenza/Swine Flu Viruses, I understand the health risks associated with exposure to such viruses. With this information, I, parent/legal guardian, of, have marked on the line preceding the choices below pertaining to the flu vaccine: Consent to the administration of the vaccine and understand the risk and benefits associated with this vaccination and accept full responsibility for my request. I surrender responsibility to the school nurse/nurse practitioner to make such a decision as to when and where my child is to receive the vaccine, taking into consideration the medical information I have provided on behalf of my child s past and current health history. Do not consent to the administration of this vaccine to my child. I accept that exposure to such viruses exist and accept full responsibility. Parent/Legal Guardian Signature Where students come to discover a love for God, respect for self, and skills for fulfilled Christian living.
7 Print Student Name Ozark Adventist Academy Tithe Information In harmony with my conviction that 10% of my earnings should be returned to the Lord, I request that tithe be withheld from my labor credit/industry earnings and remitted to the Arkansas- Louisiana Conference of Seventh-day Adventists. I prefer that tithe not be withheld from my labor credit/industry earnings. Student s Signature This form will remain in effect until the student withdraws from Ozark Adventist Academy or submits replacement form.
8 STUDENT LABOR AGREEMENT FOR (Student s Name Please print) The Seventh-day Adventist educational system has traditionally believed that the whole student should be educated. This included the idea of work. Students have worked to help defray their expenses to enable them to receive a Christian education. We will endeavor to continue that tradition, but we reserve the right not to offer employment to all students. In the past the earnings from student labor have been placed on the students accounts, and parents have paid the difference after scholarships and financial aid have been awarded. This year we are offering you and your student options as to how you want student labor handled. One option is to continue applying the student labor as a direct deposit to the student s account at Ozark Adventist Academy. With this option student labor can be considered as part of the financial plan and financial aid may be available. Another option is to direct deposit to a bank account of your choosing. There would be no student labor figured in your financial plan. Student labor may or may not be made available, but the parent would be responsible for the full payment of the account. We need to have you give us direction as to how you want the student labor handled for your student. I/We request that student labor for (Student s Name Please Print) Be applied as a direct deposit to my student s account receivable at Ozark Adventist Academy Be direct deposited to a bank account of my choosing. A voided check is attached. (Parent s Signature) () (Student s Signature) ()
9 Arkansas Department of Labor Wage and Hour Division West Markham Little Rock, Arkansas Telephone (501) * TDD: (800) APPLICATION FOR EMPLOYMENT OF A MINOR Section 1. INSTRUCTIONS 1. All sections must be completed before submitting the application. If all sections are not completed, the application will be denied. 2. As a means of establishing age, please submit a copy of one of the following documents with the application: Certificate of Birth, Driver's License, State issued I.D. card, or a notarized copy of school record listing the minor's name and date of birth. 3. The following information must be provided or the application will be denied: exact hours the minor will be working, specific job description and proof of age. NOTE: A work permit is not required for a minor 16 and 17 years of age. Section 2. STATEMENT OF PARENT, GUARDIAN OR CUSTODIAN (This statement must be completed by the parent, guardian or custodian of this child and signed by the parent, guardian or custodian, and also by the child). I, the undersigned, hereby affirm that I am the (Parent, Guardian or Custodian) of (First Name) (Middle Name) (Last Name), now residing at (Give Number and Street, City, County, State, Zip Code) and that was born in (He/She) (City) (County) (State) on the day of, 19, and is now years of age. (Month) School currently attending or last attended,, (Name of School) (Location) Child will be employed by as and I am willing that (He/She) (Give Name of Firm and Address) (Occupation of Minor) be so employed, and ask that an employment certificate be issued to said child as provided by law. (Signature of Parent, Guardian or Custodian) (Address of Parent, Guardian or Custodian) Signature of child: (Child Must Sign Own Name Here) () _
10 Section 3. INTENTION TO EMPLOY (This section is to be completed in full and signed by the employer.) This information must be provided or a permit will not be issued.) The undersigned intends to employ: (Name and Address of Minor) in the capacity of in the industry, (Occupation) for days per week, hours per day on the following days: Yes or No: Vacation employment only Employment during school year only Both (Complete only the days that apply) Monday beginning A.M. and ending P.M. Tuesday beginning A.M. and ending P.M. Wednesday beginning A.M. and ending P.M. Thursday beginning A.M. and ending P.M. Friday beginning A. M. and ending P. M. Saturday beginning A.M. and ending P.M. Sunday beginning A.M. and ending P. M. If the minor's schedule will vary, list the earliest possible beginning time and latest possible ending time. Please note that Arkansas law only allows a minor 14 and 15 years of age to work until 7:00 p.m. on nights that precede a school day and until 9:00 p.m. on nights that do not precede a school day. If your business is subject to the Fair Labor Standards Act, a minor 14 and 15 years of age can work three (3) hours per day until 7:00 p.m. on nights preceding a school day with a maximum of eighteen (18) hours per week. To obtain additional information on Federal child labor laws, you will need to contact the U.S. Department of Labor at (501) Failure to comply with these regulations will result in the application being denied. The undersigned intends to employ the above-mentioned minor immediately upon receipt of a certificate issued by the Arkansas Department of Labor and agrees to comply with the provisions of the Arkansas Statutes and the Fair Labor Standards Act relating to the employment of minors. (Employer) (Business Mailing Address) (City/State/Zip) (Employer=s Telephone Number) REMINDER: Proof of age must be attached to application or permit will not be issued. (Signature of Employer or Authorized Agent)
11 Student s Name (Please print) Drug Search and Substance Abuse Testing Permission Slip I am supportive of having a drug-free campus, and I understand there may be drug searches on campus. These searches conducted by Ozark Adventist Academy personnel, law enforcement personnel, and/or K-9 teams may include, but are not limited to lockers, dormitory rooms, and automobiles. At times it may be necessary for a breathalyzer test and/or other lab tests to be administered. I give my permission for these protective measures. If tests are administered to my student, I give permission for the release of the test results to school officials and/or law enforcement authorities. HIPPA Release Authority. For purposes of the Drug Search and Substance Abuse Testing Policy, I intend for Ozark Adventist Academy personnel and law enforcement personnel to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (a/k/a HIPPAA), 42 USC 132d and 45 CFR I accordingly authorize: Any physician, health care provider, any insurance company and the Medical Information Bureau Inc. or other health care clearinghouse that has provided treatment or services to me, to give, disclose and release to Ozark Adventist Academy personnel and law enforcement personnel, all of my individually identifiable health information and medical records regarding any present or future medical or mental health condition that in any way relates or pertains to diagnosis and treatment of drug or alcohol abuse. The authority given my agent shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given herein shall remain in effect for so long as the identified student is in attendance or enrolled at Ozark Adventist Academy. Parent or Guardian s Signature Student s Signature This form shall remain in effect as long as the student attends Ozark Adventist Academy.
12 OAA TECHNOLOGICAL RESOURCES ACCEPTABLE USE POLICY The school s information technology resources and Internet access are provided for educational purposes. Adherence to the following policy is necessary for continued access to the school s technological resources: Students must: 1. Respect and protect the privacy and well-being of yourself and others Communicate only in ways that are kind and respectful, and report any threatening or discomforting materials to a teacher or staff person. Not share private or inappropriate information about yourself or anyone else on any kind of social networking site. Not use Personals or Dating web sites or solicit inappropriate relationships using or the internet. Not intentionally access, transmit, copy, or create material that violates the school s code of conduct such as messages that are pornographic, demonic, threatening, rude, discriminatory, or meant to harass. Not intentionally access, transmit, copy, or create material that is illegal such as obscenity, threatening, stolen materials, or illegal copies of copyrighted works. Not send spam, chain letters, or other types of mass mailings. Never transmit the school's student rosters, directories, or personal information lists of any kind. 2. Respect and protect the integrity, availability, and security of all electronic resources Use only network accounts and resources that have been assigned specifically to you by the network administrator. Conserve, protect, and share these resources with other students and Internet users Not view, use, or copy passwords, login names, data, or networks to which they are not authorized. Observe all network security practices. Not attempt to bypass network filtering, monitoring or security. Report security risks or violations to a teacher, staff member, or to the network administrator. 3. Respect the educational nature of our network and the intellectual property of others Not infringe copyrights, no making illegal copies of pictures, music, games, or movies. Always fully credit the appropriate use of another person's creative resources, such as images, music and video. Not plagiarize. Not buy, sell, advertise, or otherwise conduct business, unless approved as a school project. 4. Avoid practices that use more than your share of the network resources Not making a habit of downloading or streaming software, music, or videos. Not using network resources for recreational use such as listening to radio stations or streaming music, or watching music and sports videos. Not use any computer lab in the Administration Building or Dormitories for recreational media listening or viewing purposes, or to play computer games. Not install any software on any campus computer for any reason except with express permission of the network administrator.
13 5. All students bringing their own computers for use in the dorm: Must identify their computer on the network with their first and last names as the computer name. Are to connect them to the network with a physical network cable only in their dorm room. Must keep their operating system and anti-virus software updated and legal. Microsoft Security Essentials is a recommended virus and spyware protection package that is available free from Microsoft.com. Will need to provide their own network cable to connect their computer. Wireless connections are allowed only to the school's wireless network. Students should not bring or operate their own personal wired or wireless routers. Students may, if in accord with the policy above, use our campus network and technology resources for any educational purpose. Consequences for Violations Violations of these rules may result in disciplinary action, including the loss of a student's privileges to use the school's information technology resources, connect to the school s network or have a computer in their room. It is best to remember that just because you can do something on a computer doesn t mean that you should do it. Supervision and Monitoring School and network administrators and their authorized employees monitor the use of information technology resources to help ensure that users are secure and in conformity with this policy. Administrators reserve the right to examine, use, and disclose any data found on the school's information networks in order to further the health, safety, discipline, or security of any student or other person, or to protect property. They may also use this information in disciplinary actions, and will furnish evidence of crime to law enforcement. Permission to use photograph I give permission for my/my child s photograph and /or project to be used in school publications and promotional material including but not limited to the school website. Notice Regarding Myspace.com and Other Personals and Dating Websites Definition of Site and Relevant Policies Myspace.com is a "Personals and Dating" web site. Along with other sites of its kind, Myspace.com is not allowed on campus computers, and students are blocked from accessing Myspace.com and other various sites. Furthermore, the school's "Internet Use Policy" does not allow anyone to publish texts, images, or any other information about Ozark Adventist Academy and its students, faculty, or staff without the permission of the school's administration and the technology coordinator. Regardless of where a student accesses the Internet--at home, at school, or in any other place--the student is in violation of the school's policy if the student violates this prohibition. Consequences of Violations The school cannot block every inappropriate web site, but it aggressively monitors student access to the Internet. The school keeps a record of all Internet use. A student who visits "Personals and Dating" sites or any other forbidden sites is in violation of the school's "Internet Use Policy," and computer access of students who visit such sites will be disabled for a time appropriate to the offense. Further, the school will not tolerate the use of the Internet off-campus to relate information about the school and its students, faculty, or staff. Conclusion Basing its policies on the recommendations of the NAD Technology and Distance Education Committee encourages students to use the Internet for academic purposes. The school further encourages students to act responsibly in their inevitable encounters with inappropriate web sites and s. We wish to foster behavior that promotes responsible, mature Internet use, but we will not tolerate violations of our policies or of common decency. The purpose of this notification is to repeat some of the school's Internet Use Policy, to explain the school's philosophy and particular rules and consequences, and to encourage parents to contribute to the student s healthy use of the Internet. I HAVE READ EACH OF THE ABOVE ITEMS AND ACKNOWLEDGE AND UNDERSTAND MY OBLIGATIONS: Student Parent/Guardian FOR MORE INFORMATION, SEE
14 Influenza Vaccine What You Need to Know VACCINE INFORMATION STATEMENT (Flu Vaccine, Inactivated) Many Vaccine Information Statements are available in Spanish and other languages. See Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite 1 Why get vaccinated? Influenza ( flu ) is a contagious disease that spreads around the United States every winter, usually between October and May. Flu is caused by the influenza virus, and can be spread by coughing, sneezing, and close contact. Anyone can get flu, but the risk of getting flu is highest among children. Symptoms come on suddenly and may last several days. They can include: fever/chills sore throat muscle aches fatigue cough headache runny or stuffy nose Flu can make some people much sicker than others. These people include young children, people 65 and older, pregnant women, and people with certain health conditions such as heart, lung or kidney disease, or a weakened immune system. Flu vaccine is especially important for these people, and anyone in close contact with them. Flu can also lead to pneumonia, and make existing medical conditions worse. It can cause diarrhea and seizures in children. Each year thousands of people in the United States die from flu, and many more are hospitalized. Flu vaccine is the best protection we have from flu and its complications. Flu vaccine also helps prevent spreading flu from person to person. 2 Inactivated flu vaccine There are two types of influenza vaccine: You are getting an inactivated flu vaccine, which does not contain any live influenza virus. It is given by injection with a needle, and often called the flu shot. A different, live, attenuated (weakened) influenza vaccine is sprayed into the nostrils. This vaccine is described in a separate Vaccine Information Statement. Flu vaccine is recommended every year. Children 6 months through 8 years of age should get two doses the first year they get vaccinated. Flu viruses are always changing. Each year s flu vaccine is made to protect from viruses that are most likely to cause disease that year. While flu vaccine cannot prevent all cases of flu, it is our best defense against the disease. Inactivated flu vaccine protects against 3 or 4 different influenza viruses. It takes about 2 weeks for protection to develop after the vaccination, and protection lasts several months to a year. Some illnesses that are not caused by influenza virus are often mistaken for flu. Flu vaccine will not prevent these illnesses. It can only prevent influenza. A high-dose flu vaccine is available for people 65 years of age and older. The person giving you the vaccine can tell you more about it. Some inactivated flu vaccine contains a very small amount of a mercury-based preservative called thimerosal. Studies have shown that thimerosal in vaccines is not harmful, but flu vaccines that do not contain a preservative are available. 3 Some people should not get this vaccine Tell the person who gives you the vaccine: If you have any severe (life-threatening) allergies. If you ever had a life-threatening allergic reaction after a dose of flu vaccine, or have a severe allergy to any part of this vaccine, you may be advised not to get a dose. Most, but not all, types of flu vaccine contain a small amount of egg. If you ever had Guillain-Barré Syndrome (a severe paralyzing illness, also called GBS). Some people with a history of GBS should not get this vaccine. This should be discussed with your doctor. If you are not feeling well. They might suggest waiting until you feel better. But you should come back.
15 4 Risks of a vaccine reaction With a vaccine, like any medicine, there is a chance of side effects. These are usually mild and go away on their own. Serious side effects are also possible, but are very rare. Inactivated flu vaccine does not contain live flu virus, so getting flu from this vaccine is not possible. Brief fainting spells and related symptoms (such as jerking movements) can happen after any medical procedure, including vaccination. Sitting or lying down for about 15 minutes after a vaccination can help prevent fainting and injuries caused by falls. Tell your doctor if you feel dizzy or light-headed, or have vision changes or ringing in the ears. Mild problems following inactivated flu vaccine: soreness, redness, or swelling where the shot was given hoarseness; sore, red or itchy eyes; cough fever aches headache itching fatigue If these problems occur, they usually begin soon after the shot and last 1 or 2 days. Moderate problems following inactivated flu vaccine: Young children who get inactivated flu vaccine and pneumococcal vaccine (PCV13) at the same time may be at increased risk for seizures caused by fever. Ask your doctor for more information. Tell your doctor if a child who is getting flu vaccine has ever had a seizure. Severe problems following inactivated flu vaccine: A severe allergic reaction could occur after any vaccine (estimated less than 1 in a million doses). There is a small possibility that inactivated flu vaccine could be associated with Guillain-Barré Syndrome (GBS), no more than 1 or 2 cases per million people vaccinated. This is much lower than the risk of severe complications from flu, which can be prevented by flu vaccine. The safety of vaccines is always being monitored. For more information, visit: 5 What if there is a serious reaction? What should I look for? Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. What should I do? If you think it is a severe allergic reaction or other emergency that can t wait, call or get the person to the nearest hospital. Otherwise, call your doctor. Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS web site at or by calling VAERS is only for reporting reactions. They do not give medical advice. 6 The National Vaccine Injury Compensation Program The National Vaccine Injury Compensation Program (VICP) is a federal program that was created to compensate people who may have been injured by certain vaccines. Persons who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling or visiting the VICP website at 7 How can I learn more? Ask your doctor. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call (1-800-CDC-INFO) or - Visit CDC s website at Vaccine Information Statement (Interim) Inactivated Influenza Vaccine 07/26/ U.S.C. 300aa-26 Office Use Only
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