Student Enrollment Application - Southwest Open School

Contact Information
Please provide an email address where records of this enrollment form should be sent for your convenience.
Email Address*

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Student Information
Last Name*
Full Middle Name*
First Name*
Age*
Birthdate*
MM slash DD slash YYYY
Gender*
- Female
- Male
- Other
- Prefer not to say
Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Phone Number*
Cell Phone Number
Do you consider yourself to be of Hispanic/Latino origin?*
- Yes
- No
Which of the following groups describe your ethnicity?*
You may select more than one if applicable
- American Indian or Alaskan Native
- Asian
- Black or African American
- Hispanic of any race
- White
- Native Hawaiian or Other Pacific Islander
- Two or more races
American Indian or Alaskan Native:
- Navajo
- Ute Mountain
- Northern Ute
- Southern Ute
- Other
Parent/Guardian Information
Father/Guardian Info
Full Name
Mailing Address
Home Phone
Work Phone
Cell Phone
Email Address
Mother/Guardian Info
Full Name
Mailing Address
Home Phone
Work Phone
Cell Phone
Email Address
Acknowledgement
Please sign below to indicate that you have read the entire student application packet and provided the correct information needed to enroll your child in Southwest Open School.
Student Signature*
Parent/Guardian Signature*
SWOS should mail information to:*
- Father
- Mother
- Both
Student lives with:*
- Father
- Mother
- Both
- Neither
If the student does not live with parents, please fill out the following information on the people with whom the student lives:
Full Name*
Relationship*
Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact Information
The individuals listed below have the authorization to pick up my child and can be reached during school hours at the numbers listed below:
Full Name*
Relationship*
Phone*
Full Name
Relationship
Phone
Education Background Information
Last school you attended*
Year*
School Address*
Street Address Address Line 2 City State ZIP Code
School Phone Number*
School Fax
Last grade enrolled in:*
- 8
- 9
- 10
- 11
- 12
Number of High School Credits*
Have you passed the GED?*
- Yes
- No
Are you planning on utilizing RE-1 school bus to and from school?*
- Yes
- No
Have you ever been suspended from school?*
- Yes
- No
How many times?
Have you ever been expelled from school?*
- Yes
- No
What grade were you in?

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Student Use of the Internet and Electronic Communications
Student Name*
Are you, the student, 18 years or older?*
- Yes
- No
If you are 18 years or older:

I have read, understand and will abide by the district's policy of Student Use of the Internet and Electronic Communications. Should I commit any violation or in any way misuse my access to the school district's computers or computer system, including use of the Internet and electronic communications, I understand and agree that my access privileges may be revoked and disciplinary and/or legal action may be taken.

If I am 18 years or older, I hereby release the school district from all costs, claims, damages or losses resulting from my use of district computers and computer systems, including use of the Internet and electronic communications, including by not limited to any user fees or charges incurred through the purchase of goods or services.

Your signature on this Acceptable Use Agreement is binding and indicates you have read the school district's policy on Student Use of the Internet and Electronic Communications and understand its significance.
Student Signature*
Student Date of Birth*
MM slash DD slash YYYY
If the user is under 18 years of age, a parent or guardian must sign this Agreement.

As the parent or guardian of this student, I have read the district's policy on Student Use of the Internet and Electronic Communications. I understand that access to the Internet and electronic communications is designed for educational purposes and that the school district has taken reasonable steps to block or filter material and information that is obscene, child pornography or otherwise harmful to minors, as defined by the Board. I also recognize, however, that it is impossible for the school district to prevent access to all materials or information I might find harmful or controversial and I agree not to hold the district responsible for any such materials and information accessed by my child. Further, I accept full responsibility for supervision if and when my child's Internet or electronic communications use is not in a school setting.

I hereby release the school district from all costs, claims, damages or losses resulting from my child's use of district computers and computer systems, including use of the Internet and electronic communications, including but not limited to any user fees or charges incurred through the purchase of goods or services.

I hereby give permission to issue an Internet and electronic communications account for my child and certify that the information contained on this form is true and correct.

Your signature on this Acceptable Use Agreement is binding and indicates you have read the district's policy on Student Use of the Internet and Electronic Communications carefully and understand its significance.
Parent/Guardian's Name*
Today's Date*
MM slash DD slash YYYY
Parent/Guardian Signature*

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Notice of Trip Procedures Regarding Illegal Substance Possession/Use
While your child is a student at SWOS, it is highly likely that he/she will be taking a trip with their class. Class trips are an important part of the curriculum and it is expected that students participate in trips that are a part of their class content. Parents receive a trip itinerary and information regarding the trip. Teachers are available to answer any questions parents may have concerning trips both before and after the trip.

While a student is on a SWOS trip, it is imperative that a high trust level be established between staff and students. When SWOS staff takes your child on a trip, all SWOS norms must be followed. It is illegal for students to possess or use drugs or alcohol on the school grounds or on any school sponsored activity. If a student possesses or uses drugs or alcohol on a SWOS trip, that student will be expelled from SWOS for the remainder of the school year. The parent is immediately notified and will become responsible for transporting that student home. Please sign the form below to indicate that you understand you will take over responsibility for your child if they possess or use illegal substances on a SWOS trip.

I understand that I will have to accept full responsibility for my child if he/she chooses to possess or use illegal substances on a SWOS trip. This means I will have to make immediate arrangements for my child to be transported back home ASAP.
Child's Name*
Parent/Guardian Name*
Parent/Guardian Signature*
Today's Date*
MM slash DD slash YYYY

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Photography Consent Form Release
Are you, the student, 18 years or older?*
- Yes
- No
Release of Adults (18 Years or Older)
I
Name*
, hereby grant permission to Southwest Open High School, its employees or representatives, to take and use photographs, videotape and digital images of me for use in promotional or educational materials. These materials might include printed or electronic publications, websites or other electronic communications. I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images indefinitely without compensation to me. All negatives, positives, prints, digital reproductions and videotape shall be the property of Southwest Open School.
Signature of Adult Subject*
Today's Date*
MM slash DD slash YYYY
Release of Minor Children (Under 18)
I
Parent/Guardian Name*
, parent or official guardian of
Child's Name*
, hereby grant permission to Southwest Open High School, its employees or representatives, to take and use photographs, videotape and digital images of my child for use in promotional or educational materials including printed publications or materials, electronic publications or presentations and websites. I agree that my child's name and identity
Untitled*
- may be revealed
- may not be revealed
in descriptive text or commentary in connection with the image(s). I authorize the use of these images indefinitely without compensation to me. All negatives, positives, prints, digital reproductions and videotape shall be the property of Southwest Open School.
Signature of Parent/Guardian*
Today's Date*
MM slash DD slash YYYY

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Acknowledgment & Assumption of Risks & Indemnity Agreement
INTRODUCTION

Please read this entire Acknowledgment & Assumption of Risks and Release & Indemnity Agreement (hereafter, "Document") carefully before signing. The student (hereafter, "participant") must sign this Document. If participant is under 18 years of age (hereafter sometimes "minor" or "child"), one of the participant's parents or legal guardians, or both (hereafter collectively "parent/s"), if available, must also sign. In consideration of the services of Southwest Open School, a 501(c)(3) non-profit charter school association (referred to in this Document as "SWOS"), in allowing participant to participate, I (participant and parent/s of a minor participant) acknowledge and agree as follows:

ACTIVITIES, RISKS AND ACKNOWLEDGMENT AND ASSUMPTION OF RISKS

Participating (whether simply attending, observing or actively participating) in SWOS year-round educational, experiential, instructional, recreation and/or adventure activities associated with academic programs, curricular or co-curricular activities or otherwise, includes risks. These activities can take place on or off SWOS premises in Colorado or in other locations in the United States and/or in foreign countries. Activities, which may be led or conducted by SWOS staff, volunteers, contractors or others, may include, but are not limited to: classroom activities; competitive or non-competitive athletic sports and/or games, practices and events; P.E. and other athletic activities, including use of weights and weight room activities; hiking; backpacking; camping (winter and summer); cross-country, alpine or back-country skiing, snowshoeing, snowboarding and other outdoor winter activities; rock climbing or bouldering (indoors or outdoors on artificial surfaces or natural rock), canyoneering and use of low or high ropes courses, challenge courses or zip lines (all of which may include use of ropes, harnesses and/or other technical gear); rafting, kayaking, canoeing, or other boating, including riding in chartered motor boats; swimming in pools, rivers, lakes, and/or oceans; road and mountain bicycling; urban and/or trail running; horseback riding; archery; welding; glass blowing; day or multi-day field trips or other trips; service learning projects; SWOS club or intramural activities; use of homestays and other accommodations; use of any equipment, facilities or premises; travel in airplanes, vans, buses or other vehicles to and from SWOS or during trips, events or otherwise (collectively referred to in this Document as "activities"). Activities may take place as mandatory or optional segments during the SWOS academic year or summer curriculum, and may be scheduled or unscheduled, supervised or unsupervised, and include activities undertaken during participant's free and/or independent time. Participant and parent/s ofa minor acknowledge that participant's choice to socialize or participate in activities with SWOS staff members outside school hours and/or unrelated to a SWOS organized field trip, outing or program is not a SWOS related activity, and participant does so entirely at their own risk. I, (and my parent/s, if I am a minor) acknowledge that the inherent and other risks, hazards and dangers (collectively referred to in this Document as "risks") of these activities can cause injury, damage, death or other loss to participant or others. Parent/s of minor participants agree to discuss the nature of these activities and risks with their child and give their child permission to participate in all SWOS activities. The following describes some, but not all of those risks:

Risks present in an outdoor environment. These risks include travel in high altitude (up to or possibly above 13,000 ft.), mountainous, desert and/or wilderness terrain, both on and off trail and on land or water. Participants' travel may be subject to storms, including rain, lightning, strong winds, snow or ice; tides, currents, waves, reefs or whitewater; extremely hot (geothermal) or cold water or weather and rapid and unpredictable weather changes; flash floods; mud or rock slides; fast moving rivers, oceans or other water bodies; difficult stream and/or snowbridge crossings; falling or slippery rocks; falling or fallen timber; avalanche dangers; stinging, venomous and/or disease carrying animals, insects or microorganisms; poisonous plants; wild or domestic animals and other natural or man-made hazards. Hazards (both on land and above or below water level) may not be marked or visible and weather is always unpredictable.

Equine risks. Riding or dealing in any way with horses (including donkeys, mules or ponies) includes risks. Horses are unpredictable in all circumstances and, without warning, can kick, bite, stomp, stumble, rear, bolt, fall down, and react to the environment, sudden movements, noise, light, vehicles, people, other animals or objects. Horseback riding can involve equipment that may fail, saddles that may slip and other riders who may not control their animals. WARNING: Under Colorado law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to section 13-21-119, Colorado Revised Statutes.

Decision making and conduct risks. These risks include the risk that the participant or a fellow participant, SWOS staff member, contractor, or other person may misjudge the participant's (or others) capabilities, health or physical condition, or misjudge some aspect of travel, instruction, medical treatment, weather, terrain, water conditions or water level or route location. These risks also include the participant's judgment in managing his or her own health issues, including any responsibility for self-medication.

Personal health and participation risks. The participant's mental, physical or emotional condition (including use or abuse of alcohol or any prescription or non-prescription drugs), disclosed or undisclosed, known or unknown, combined with participation in these activities includes risks. Although SWOS personnel may review participant's health and medical information, SWOS cannot anticipate or eliminate risks or complications posed by participant's mental, physical (including fitness level) or emotional condition.

Risks associated with any active, athletic and/or competitive activity. Participating in, training or conditioning for, and/or practicing and competing in any activities can involve frequent and repetitive use of the arms and legs, lifting or carrying weight, balancing, coordination and endurance. Risks include that a participant may overestimate his or her abilities or fitness; be inattentive; lose control and trip or fall and/or collide with others, the ground, rocks or trees or encounter other water/terrain/road/trail/other hazards; not understand the functioning of (or misuse) the equipment; fail to negotiate steep, uneven or difficult terrain; not control his or her speed or experience equipment malfunction.

Service learning project risks. Risks include those associated with activities such as building, digging, lifting, construction, maintenance and repair (including trail work). Projects may involve the use of tools and equipment (i.e. hand tools, power tools, hammers, ladders) and substances (paints, cleaning agents) that can cause injury resulting from use, misuse or malfunction.

Geographic location risks. Activities may take place in remote locations, several hours or up to a day from medical facilities, causing potential delays or difficulties in communication, transportation, evacuation and medical care. Medical facilities may sometimes be primitive, inadequate or inaccessible. Additional delays can result if circumstances require transport from a foreign country back to the U.S. for medical care. Although SWOS staff or contractors may have access to wireless communication devices, use of these devices (whether inside or outside the U.S.) in outdoor or wilderness terrain and/or in any other terrain or location is unreliable and inconsistent.

Risks associated with premises. Participants may cook, or engage in other chores on SWOS premises. In addition, boulders, ruts, slippery walkways, uneven ground or other conditions may exist in and around the SWOS grounds.

Equipment risks. The risk that equipment used in an activity may be misused, or may break, fail or malfunction. This includes participant's personal equipment, SWOS equipment or any other equipment (whether purchased, borrowed, or rented). Participants choosing to bring and use their personal equipment (including any safety gear) assume full responsibility, along with parent/s of minors, for choosing appropriate equipment and for the fit and condition of their equipment. Helmets or other safety gear (required or used for some activities) may prevent or lessen injuries in some instances; however, use of safety gear is not a guarantee of safety, and injury can occur even with the use of this gear.

Boating and swimming risks. These risks include potential water obstacles or hazards such as rapids, boulders, trees/bushes and branches, ropes, fences, other boats; waterfalls, holes, reversals; slipping on wet rocks or boat ramps or jumping off rocks into the water; falling overboard; impact with rocks/equipment/the river bottom/other people; being swept into a river current; or experiencing a boat capsize or collision.

Climbing risks. Whether climbing, or using zip lines or ropes or challenge courses, risks include the possibility of slipping and falling partway or to the ground; burns; pinches; jolts; belayer inattention or error; losing grip on the rock or a climbing hold; impacting the rock face, a climbing tower, cable, objects or people; being hit by rock or debris fall from above; loose or damaged climbing holds; and equipment failure or misuse.

Cooking, camping and travel risks. While camping or otherwise, participants may cook over a gas or propane stove and are subject to the risk of gas explosion, scalding or other burns. Contaminated water is a risk in natural or primitive settings and water may be disinfected, filtered or boiled before use. Food or water is also provided by vendors, contractors, host families or public restaurants with risks of contamination or allergic reaction. Camp sites may be subject to falling trees and/or branches, floods, wildlife disturbances, and other hazards.

Free or unsupervised time. Participants may have free or unsupervised time during sleeping hours, before, during and after the start of an activity, and at various other times. Unsupervised time may include free time and/or brief periods of time outdoors, stationary and alone (solo). During both supervised and unsupervised activities, all participants share in the responsibility for their own well-being.

U.S. and International travel risks. Travel inside or outside the U.S. can involve unique risks such as political unrest, terrorism, contact with unusual diseases, exposure to contaminated food or water, dangerous road or travel conditions, thievery, abduction and other risks. Participants may be subject to laws and legal systems in foreign countries that do not provide the same protections as the U.S. legal system. NOTE: Although SWOS considers current gee-political climates in choosing international program locations, SWOS personnel are not experts in assessing the likelihood of terrorist activity, political unrest, the need for vaccinations or other issues. The participant and his or her parent/s are responsible for conducting their own independent investigation through the U.S. State Department, U.S. Centers for Disease Control, World Health Organization or other sources, should they have any concerns about program locations.

Risks regarding conduct. The potential that the participant, other participants or third parties, may act carelessly or recklessly.

These and other risks may result in participants: falling partway or falling to the ground or into the water; being struck by, colliding with or impacting objects, people, vehicles, animals, the rock face or the bottom of a water body; experiencing vehicle or boat collision, capsize or rollover; getting caught or entangled in objects above or below water; reacting to high altitudes, weather conditions or increased exertion; becoming lost or disoriented; suffering gastro-intestinal complications or allergic reactions or experiencing other problems. These and other circumstances may cause heat or cold related illnesses or conditions (including hypothermia, hyperthermia, cold water immersion, frostbite or heat exhaustion/stroke); dehydration; hyponatremia; drowning; high altitude sickness (e.g. high altitude pulmonary or cerebral edema); heart or lung complications; broken bones; paralysis or other permanent disability; mental or emotional trauma; concussions; sun burn or other burns; illnesses (including contracting animal/insect borne or contagious diseases); infections; cuts; wounds; or other injury, damage, death or loss.

I (participant and parent/s of a minor participant) agree:
- to accurately review all information received, complete and abide by all required forms, and obey SWOS rules and other policies;
- SWOS representatives are available should I have further questions about these activities or the associated risks;
- to disclose any mental, physical or emotional condition/s or limitation/s which might affect participant's ability to participate, and represent that participant is fully capable of participating without causing harm to him or herself or others;
- participant and parent/s of a minor are responsible for any lost, stolen or damaged equipment;
- SWOS contracts with individuals or organizations that are independent contractors (not employees or agents of SWOS) to provide or conduct some of the services and activities participants will engage in. SWOS does not supervise or control these contractors and is not legally liable or responsible for their conduct. In addition, organized and/or competitive activities, including competitions, meets, events and races are often organized by third parties and/or take place on premises or at facilities not owned by, or associated or affiliated with, SWOS. SWOS does not oversee, supervise, or take responsibility for any aspect or condition of these independent services, activities, facilities or premises. Participant and parent/s of a minor acknowledge that they may independently inspect and assess any of these services, activities, facilities or premises, if they choose to do so;
- the information provided above is not complete, other unknown or unanticipated activities, risks and outcomes may exist, and SWOS cannot assure participant's safety or eliminate any of these risks;
Participant is voluntarily participating with knowledge of the risks. Therefore, participant (and parent/s of a minor) assume and accept full responsibility for participant, for the inherent and other risks (known and unknown, described above or otherwise) of these activities and for any injury, damage, death or other loss suffered by participant (and parent/s of a minor), resulting from those risks, including the risk of participant's own negligence or other misconduct.

RELEASE AND INDEMNITY AGREEMENT

Please read carefully. This Release and Indemnity Agreement contains a surrender of certain legal rights. I (adult participant, or parent/s for themselves and for and on behalf of their participating minor child) agree as follows:

1) to release and agree not to sue SWOS, the Montezuma Cortez RE-1 School District, and each of their respective officers, directors, teachers or other employees, agents, representatives and volunteers, including but not limited to leaders, guides and mentors, and all related or affiliated individuals or entities (hereafter individually and collectively "Released Parties"), with respect to any and all claims, liabilities, suits or expenses (including attorneys' fees and costs) (hereafter "claim" or "claim/s"), for any injury, damage, death or other loss in any way connected with my/my child's enrollment or participation in these activities, including use of any equipment, facilities or premises. I understand I agree here to waive all claim/s I or my child may have against the Released Parties, bind my/my child's estate and any family member/heir/other party bringing claim/s, and agree that neither I, my child nor anyone acting on my or my child's behalf, will make a claim against the Released Parties as a result of any injury, damage, death or other loss suffered by me or my child;

2) to defend and indemnify the Released Parties ("indemnify" meaning protect by reimbursement or payment), with respect to any and all claim/s brought by or on behalf of me, my participating child or spouse, my/my child's other family member/s, heir/s or estate, a co-participant or any other person for any injury, damage, death or other loss in any way connected with my/my child's enrollment or participation in these activities, including use of any equipment, facilities or premises.

This Release and Indemnity Agreement includes claim/s of or resulting from the Released Parties' negligence (but not any of their gross negligence or willful, wanton or reckless misconduct), and includes claim/s for personal injury or wrongful death (including claim/s related to emergency, medical, drug and/or health issues, response, assessment or treatment), property damage, loss of consortium, breach of contract or any other claim.

OTHER PROVISIONS

I (participant and parent/s of a minor participant) further agree:
- Colorado substantive law (without regard to its "conflict of law" rules) governs this Document, any dispute I or my child have with the Released Parties and all other aspects of my or my child's relationship with the Released Parties, contractual or otherwise, and I agree that any mediation, suit or other proceeding must be filed or entered into only in Montezuma County, Colorado. I agree to attempt to settle any dispute (not settled by discussion) through mediation before a mutually acceptable Colorado mediator;
- I authorize SWOS staff, representatives, contractors or other medical personnel to obtain or provide medical care for me/my child, to transport me/my child to a medical facility, and to provide treatment they consider necessary for my/my child's health. I agree to pay all costs associated with that care and transportation. I agree to the release (to or by SWOS) of any medical records necessary for treatment, referral, billing or insurance purposes;
- SWOS reserves the right to remove any participant from any activities, if staff believe, in their judgment, the participant presents a safety concern or medical risk, is disruptive, or engages in illegal or offensive conduct. Use of illegal drugs, tobacco products or alcohol are examples of conduct that can lead to early dismissal. If participant is dismissed or departs for any reason, participant (and his/her family) are responsible for all costs of early departure whether for medical reasons, dismissal, personal emergencies or otherwise;
- I authorize SWOS or parties it designates the right and permission to photograph, film, record and/or otherwise capture my or my child's name, image, voice, written statement, photograph and/or visual likeness and use those in any media throughout the world, in perpetuity, including for reproduction, display or otherwise on the worldwide web or in publications, film or other form for educational, promotional or other purposes, without compensation to me or my child. I agree that SWOS owns all ownership/copyright rights and I waive any privacy, inspection or approval rights;
- This Document is intended to be interpreted and enforced to the fullest extent allowed by law. If any portion of this Document is deemed unlawful or unenforceable, it shall not affect the remaining provisions, and those remaining provisions shall continue in full force and effect;
- This Document is effective in regard to the participant's enrollment or participation in all activities from the date signed until a subsequent SWOS Acknowledgment and Assumption of Risks & Release and Indemnity Agreement is signed by the participant (and parent/s of a minor participant), and shall remain in full force and effect for all activities completed by the participant up until that point.
Participants and parents of a minor participant: I have carefully read, understand and voluntarily sign this Document and acknowledge that it shall be effective and legally binding upon me, my spouse, participating minor child and other children, and parent/s/participant's other family members, heirs, executors, representatives, subrogors, assigns and estate. The participant must sign below. If participant is a minor (under 18 yrs. of age), one of the minor's parents or legal guardians, or both, if available, must also sign below.
Participant Name*
Participant Signature*
Today's Date*
MM slash DD slash YYYY
1st Parent/Guardian Name*
1st Parent/Guardian Signature*
Today's Date*
MM slash DD slash YYYY
2nd Parent/Guardian Name
2nd Parent/Guardian Signature
Today's Date
MM slash DD slash YYYY

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Permission to Treat for Illness or Injury and Secure Emergency Services
I give permission for my child
Child's Name*
to participate in any Southwest Open School (SWOS) field trips. In the unlikely event of an accident involving my child, I request that the trip leader (s) secure emergency services (in-eluding rescue, evacuation, and medical treatment) for my child and grant them legal permission to sign for such emergency services. I agree to incur any additional expenses associated with such action. As parents/guardians, we understand that field trips are a significant part of SWOS curriculum. I have decided that our child is physically, mentally, and socially able to participate in these field trips. I acknowledge that any medical or accident insurance we consider necessary will be our responsibility to locate and purchase. I have read and agree to these terms and do hereby release SWOS and its employees and volunteers from liability for damages, injuries, or losses that may occur while my child is on a SWOS field trip.

SWOS staff has my permission to give my child:
Medicine Options
- Tylenol
- Ibuprofen
- Antacids
- Cough Dropds
Parent/Guardian Name*
Parent/Guardian Signature*
Today's Date*
MM slash DD slash YYYY
In an emergency, contact me at:
Phone Number*
If you cannot reach me, please contact:
Secondary Emergency Contact Name*
Secondary Emergency Contact Phone Number*

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SWOS Insurance and Liability Form
The following form is required for participation in the Southwest Open School program.

Your signature at the bottom of this form affirms that you have read and understood the following:
1. I am aware that SWOS does not provide liability medical coverage for my child during this program. At SWOS, my child will be involved in on-campus and off-campus activities that involve some inherent risk.
2. It is recommended that your child be covered by a major medical insurance policy during the school year.
3. My child is adequately covered by major medical insurance policy during the times of the above program dates. Listed below is our insurance policy information.
Insurance Company Name*
Insurance Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Phone Number*
Insurance Policy Number*
No Insurance
- Check this box if you do not have any insurance. As the parent/guardian, I will be responsible for any medical payments that might arise.
Parent/Guardian Name*
Parent/Guardian Signature*
Today's Date*
MM slash DD slash YYYY

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Armed Forces Recruiting
Important Notice to Parents - Armed Forces Recruiter Access to Students & Student Recruiting Info

The "No Child Left Behind Act of 200 l" passed certain new requirements with respect to Armed Forces Recruiter Access to Students and Student Recruiting Information:
- Duty to provide information to Military Recruiters: Unless the parent otherwise request, the District must provide upon request by military recruiters access to high school student's name, address and telephone listings.
- Consent: Either the high school student or the parent of the student may request that the student's name, address and telephone listing not be released without the prior parent consent. Schools are required to notify parents of this option to make a request and shall comply with the request.
- Access to students: Each district shall provide military recruiters the same access to high school students as is provided generally to higher education institutions, community colleges and prospective employers.
If you DO NOT want your student's name, address and telephone listing released to Armed Forces recruiters, YOU MUST SIGN THIS FORM.

Your statement of objections will not be placed in your child's records, and we will not release this information to military recruiters without your written consent.
DO NOT RELEASE MY STUDENT'S INFORMATION
Preferred Name
As parent/guardian of
Untitled
Student Name
I do not give permission for the Southwest Open High School to release any information regarding the above student to any branch of the US Military.
Parent/Guardian Signature
Today's Date
MM slash DD slash YYYY

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4CYC - General information
Mission: Keep children and youth healthy, in school, and ready to learn.

Vision: All students have a right to access quality integrated health care in a caring and supportive environment that optimizes education, health, and well-being.

Facts:
- Services are available to all students in Montezuma County.
- For medical health services, insurance is accepted (Medicaid, CHP+ and private insurance).
- A sliding scale applies for uninsured patients.
- For behavioral health services, uninsured and private insured patients will be placed on a sliding fee scale.
- Additional charges might apply for laboratory tests.
- Each month, a patient statement indicating full charges, discounts and balance will be mailed to the home address.
- No one will be turned away due to inability to pay.
- Appointments are preferred, but walk-ins are accepted (when available).
To Make Appointments:
- Southwest Open School campus: Please call 970-560-5056
- Dolores School District campus: Please call 970-560-4890
Registration forms may be dropped off at the clinics, emailed to [email protected], or faxed to 970-564-1654 (Cortez) or 970-459-3120 (Dolores). Staff:

Staff:
- Michelle Rhonehouse, FNP - Nurse Practitioner
- Patricia Nelson, LPC – Behavioral Health Provider
- Eli Cover, LPC – Behavioral Health Provider
- Julie Hite, RN – Registered
- Karen Ragland – Medical Receptionist/LPN - SWOS
- Amy Gordanier – Medical Receptionist – SWOS
- Debra Frans – Medical Receptionist – Dolores
- Sarah Jones – Program Manager
Typical Conditions Seen at the School-Based Health Center:

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Four Corners Youth Clinics - Consent for Treatment
Consent for Treatment - Parental Guardian, Emancipated Minor, Adult Student

Parental Consent: I understand that my child may be seen at Four Corners Youth Clinics (4CYC) only with my consent if under 18 years of age or not emancipated, or able to provide minor consent in accordance with Colorado state law, and that this consent will remain in force through the age of 21 or until I revoke said consent in writing. It is my responsibility to notify the clinic about changes in guardianship or insurance. The only exceptions to this policy are: a student may be seen one time to discuss the need for services; services will be provided in case of any emergency.

Release of Information: 4CYC is a HIPAA compliant school-based health center. Information in my child’s healthcare record is confidential and will not be released to any unauthorized person or agency without written consent. In conformance with Colorado law guiding all medical facilities, my son/daughter may request that visits and health information remain confidential, under some circumstances. For me or any other party to have access to healthcare records regarding such information, my child must complete a written release.

Data Sharing Information: I understand that the Colorado Department of Public Health and Environment (CDPHE) provides funding for health services I/my child receives at this school-based health center and is legally able to receive information regarding services provided to patients. CDPHE receives combined data for all patients, and this data does not specifically identify any individual patient.

Coordination of Care/Billing: I authorize 4CYC to disclose all or any portion of my child’s healthcare record to any person or entity performing record keeping or billing services for the 4CYC and any person or entities performing billing on behalf of 4CYC. I give consent to the 4CYC staff to review my child’s school records, attendance, and other records that may assist 4CYC providers to help my child. I also authorize the staff of 4CYC to disclose all or any portion of my child’s medical record to persons or entities pertinent to his/her health care, including his/her primary care provider, school nurse or school health paraprofessionals, mental health providers, Every Child Pediatrics staff, the Food Service Director, the Montezuma County Public Health Department, and/or employees of the Dolores School District RE-4A/Montezuma-Cortez School District RE-1 who, as determined by 4CYC, are closely involved with monitoring my child’s welfare and have a reasonable need to know such information. I understand that if my child is scheduled for an overnight school trip, basic medical information such as allergies, immunization status, past medical history, and current meds may be shared with the supervising teacher to provide for a safe and healthy environment during the trip. I also give consent to access my child’s school immunization information and for it to be entered into the Colorado Immunization Information System (CIIS).

I give my consent for the named patient to receive necessary and/or advisable health services from the staff of 4CYC.
Acknowledgement of Receipt*
- I acknowledge receipt of the Notice of Privacy Practices and Patient Bill of Rights and Responsibilities
Patient Name*
PRINTED name of Parent/Gaurdian*
SIGNATURE of Parent/Guardian*
Date*
MM slash DD slash YYYY

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Income Attestation for Sliding Fee Scale
Legal Patient Name*
Date of Birth*
MM slash DD slash YYYY
You must answer the questions below IF YOUR CHILD DOES NOT HAVE HEALTH INSURANCE or Medicaid (or if your child's insurance or Medicaid/CHP+ application is pending). If your child does not have health insurance benefits that will cover the cost of his/her visit today, you do not need to answer these questions.
Behavioral health services are limited to billing medicaid and United Health/RMHP at this time. All other rendered services for behavioral health will need to be on a sliding fee scale fir uninsured patients and patients with private insurance coverage. Payment is collected at the time of the appointment.
How many people live in your Household?*
Roughly, what is your family's gross total income per year, before taxes?*
I certify that the above family financial information is true and accurate to the best of my knowledge. I understand that this information needs to be updated yearly, and I will be asked to sign this form at such time. You may also update this form as your income changes at any time.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY

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Notice of Privacy Practices for Protected Health Information
This school-based health center is permitted by federal privacy laws to make uses and disclosures of your protected health information for the purposes of treatment, payment, and healthcare operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

TREATMENT: We will use and disclose your protected information to provide, coordinate or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example, if, during the course of your treatment, the physician determines he/she will need to consult with a specialist, he/she will share the information with such specialist and obtain his/her input

PAYMENT: Your protected health information will be used, as needed, to obtain payment for your health care services. If the health insurance company requests information from us regarding your care, we will provide that information to them.

HEALTHCARE OPERATIONS: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services and insurance. We will share information about you with such business associates as necessary to obtain these services; or a school nurse, school health paraprofessional or daycare provider to assure children attend school in a healthy state.

We may use or disclose, as needed, your protected health information in the following situations without your authorization. These situations include: as Required by Law, Communicable Disease, Health Oversight Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, Required Uses and Disclosures. Under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine compliance.

YOUR HEALTH INFORMATION RIGHTS

The health and billing records we maintain are the physical property of Every Child Pediatrics. The information in it, however, belongs to you. You have the following right:

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means that you may ask not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.You have the right to obtain a paper copy of this notice, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You have the right to have your physician amend your protected health information.If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you, by mail, of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints:You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected information. If you have any objections to this form, please ask to speak to our HIPPA Compliance Officer in person or by phone at our main number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices.
Print Name*
Signature*
Date*
MM slash DD slash YYYY
Patient Name*
Date of Birth*
MM slash DD slash YYYY
Patient Notification of the Use of Health Information Exchange

Every Child Pediatrics endorses, supports, and participates in the electronic Health Information Exchange (HIE) as a means to improve the quality of your child’s health and healthcare experience. HIE provides us with a way to securely and efficiently share your child’s clinical information electronically with other physicians and healthcare providers that participate in the HIE network. Using HIE helps your child’s healthcare providers to more effectively share information and provide your child with better care. The HIE also enables emergency medical personnel and other providers who are treating your child to have immediate access to their medical data that may be critical for their care. Making your child’s health information available to their healthcare providers through the HIE can also reduce costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt out of, on behalf of your child, participation in Every Child Pediatrics HIE, or cancel an opt- out choice at any time.

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Patient Bill of Rights and Patient Responsibilities
Four Corners Youth Clinics support the rights of all patients. These rights may be exercised through the patient individually or through their surrogate decision-maker/legal representative.

You have the right to…
- Be informed of your patient rights in advance of receiving or discontinuing care.
- Have impartial access to care. No one is denied access to treatment because of disability, national origin, culture, age color, race, religion, gender identity, or sexual orientation. No one is denied treatment of an emergency medical condition because of their source of payment.
- Give informed consent for all treatment and procedures with an explanation in layman terms of:
  - a. Recommended treatment or procedure
  - b. Risks and benefits of the treatment or procedure
  - c. Likelihood of success, side effects and risks including death
  - d. Alternatives and consequences if treatment is declined
  - e. Explanation of the recovery period
- Participate in all areas of your care-plan, treatment, care decisions, and discharge plans.
- Have appropriate assessment and management of your plan.
- Be informed of your health status.
- Be treated with respect and dignity. Personal privacy, comfort and security to the extent possible during your time at the clinic.
- Be free from seclusion or restraints.
- Confidentiality of all communication and clinical records related to your care.
- Have access to telephone calls.
- Have the right to choose a visitor who maybe with you during your visit as appropriate.
- Have access to interpreter services at no cost to you.
- Receive care in a safe setting.
- Be free from all forms of abuse or harassment.
- Have access to protective services.
- Request medically appropriate and necessary care.
- Refuse any drug, test, procedure, or treatment and be informed of the medical consequences of such a decision.
- Consent or refuse to participate in any study, trial, research program.
- Receive information about Advance Directives per request.
- Participate in decision-making regarding ethical issues, personal values or beliefs.
- Have access to your clinical records within a reasonable timeframe.
Patient Responsibilities:
- Ask questions and promptly voice concerns.
- Give full and accurate information as it relates to your health, including medications.
- Report changes in your condition or symptoms, including pain and request assistance of a member of the health team.
- Participate in the planning of your care, including discharge planning.
- Follow your recommended treatment plan.
- Be considerate of other patients and staff.
- Secure your valuables.
- Follow facility rules and regulations.
- Respect property that belongs to the clinic.
- Understand and honor financial obligations related to your care, including understanding your own health insurance.
Note: A copy of this document can be provided to you at the time of your appointment if requested.

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Contact Information

Please provide an email address where records of this enrollment form should be sent for your convenience.

Student Information

Parent/Guardian Information

Father/Guardian Info

Mother/Guardian Info

Acknowledgement

Emergency Contact Information

Education Background Information

Student Use of the Internet and Electronic Communications

If you are 18 years or older:

If the user is under 18 years of age, a parent or guardian must sign this Agreement.

Notice of Trip Procedures Regarding Illegal Substance Possession/Use

Photography Consent Form Release

Release of Adults (18 Years or Older)

Release of Minor Children (Under 18)

Acknowledgment & Assumption of Risks & Indemnity Agreement

INTRODUCTION

ACTIVITIES, RISKS AND ACKNOWLEDGMENT AND ASSUMPTION OF RISKS

RELEASE AND INDEMNITY AGREEMENT

OTHER PROVISIONS

Permission to Treat for Illness or Injury and Secure Emergency Services

SWOS Insurance and Liability Form

Armed Forces Recruiting

DO NOT RELEASE MY STUDENT'S INFORMATION

4CYC - General information

Four Corners Youth Clinics - Registration Form

Every Child Pediatrics - Medical Sponsor

Family Information

History Form

Four Corners Youth Clinics - Consent for Treatment

Consent for Treatment - Parental Guardian, Emancipated Minor, Adult Student

Income Attestation for Sliding Fee Scale

Notice of Privacy Practices for Protected Health Information

YOUR HEALTH INFORMATION RIGHTS

Patient Notification of the Use of Health Information Exchange

Patient Bill of Rights and Patient Responsibilities

Authorization for Disclosure of Protected Health Information

Southwest Open School School Nurse Health Consent

Name and Phone # of person to contact regarding medical questions or concerns:

Links