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Academic Day School
Admission Packet
Have you completed and submitted the Application Referral Packet?
The Application Referral Packet can found on the website,
https://timber-ridge-school.org/admissions/application.php.
It must be submitted before or with this service admission packet.
Please complete and return forms to [email protected]
Or Mail/fax to
Timber Ridge School
PO Box 3160
Winchester, VA 22604
540-888-3456
Fax: 540-888-4511
Accreditation:
Member:
Council on Accreditation
AdvancED - Southern Association of Colleges and Schools
National Commission for the Accreditation of Special Education Services
Virginia Association of Independent Specialized Education Facilities
National Association of Private Special Education Centers
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.5
Informed Consent
Placement Agreement:
Academic Day School
Page 1 of 5
Last Revision: 5/7/14
ACADEMIC DAY SCHOOL 2014-2015
INFORMED CONSENT PLACEMENT AGREEMENT
STUDENT’S NAME:
Birthdate:
Sponsor Agency:
This Agreement is between
, as the
custodian of or the representative of the agency with custody of the above-named child, hereinafter
referred to as “Custodian”, and the Leary Educational Foundation, Inc., dba TIMBER RIDGE SCHOOL,
1463 New Hope Road, Cross Junction, Virginia 22625, hereinafter referred to as “TIMBER RIDGE
SCHOOL”, to wit:
1.
CUSTODY.
a. The child shall be placed with TIMBER RIDGE SCHOOL to provide instruction, care, and
guidance to the child while this agreement remains in effect.
b. The Custodian shall retain legal custody of the child.
2.
MEDICAL CARE.
a.
TIMBER RIDGE SCHOOL shall ensure that the child receives routine school nurse care to
include administering prescription medications provided by the Custodian and as prescribed
by the child’s physician. .
b. TIMBER RIDGE SCHOOL shall act with propriety in medical emergencies, notifying the
Custodian as soon as possible with regard to emergency situations.
c.
The Custodian agrees to bear the expenses of medical and dental care, including
prescription medications.
3.
CONFIDENTIALY. The services a child receives are confidential, private, and personal. Your
written permission is required for the release of information except in situations of clear and
imminent danger to yourself or others, court subpoena, or suspicion of child abuse or neglect and
as required by law.
4.
SERVICES.
a. TIMBER RIDGE SCHOOL shall provide educational services to the child consistent with
licensure and accreditation provisions and as specified in the child’s IEP/IIP.
b. Counseling/Therapy. Counseling and therapy can have benefits and risks. Therapy
often involves discussing unpleasant aspects of the child’s life; he may experience
uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and
helplessness. On the other hand, therapy services can have benefits such as: better
relationships, solutions to problems, and decreased feelings of distress. But there are no
guarantees of what he will experience. Therapy services may improve his ability to relate
to others, provide a clearer understanding of himself, his values and goals, and an ability
to deal with everyday stress. It is essential that the child discuss any questions or
discomfort he may have with his Counselor.
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.5
2210.6
Placement
PlacementAgreement:
Agreement
Academic Page
Day School
2 of 3
Page 2 of 5
Last Revision: 5/7/14
c.
5.
As legal guardian for the child, you have received information containing program
information and expectations [i.e. Behavior Support and Management Acknowledgment
(Form #2210.31), a copy of the Behavior Management System used during the Academic
Day School].
CONTACTS WITH FAMILY AND FRIENDS.
a. TIMBER RIDGE SCHOOL shall confer with the Custodian concerning the child’s
development, activities, and problems while the child is in the care of the facility, providing
written progress reports at least quarterly.
b. The Custodian hereby denies permission for the following relatives or friends to contact or
pick up the child at TIMBER RIDGE SCHOOL.
6.
AUTHORITY TO PLACE. The Custodian represents that the Custodian has the legal authority
to place the child at TIMBER RIDGE SCHOOL.
7.
ABSENCES FROM THE FACILITY. Child absences from the class shall be reported as they
occur. Absences such as “away without authorization”, may or may not result in discharge, and
will be determined on a case by case basis with the placing agency. Custodian will pay for
services even in the event of absence essentially supporting the enrollment space. Any planned
absences exceeding five (5) days must be cleared by the Local Educational Agency.
8.
PAYMENT FOR SERVICES.
a. The Sponsor Agency, which may or may not be the Custodian, shall be responsible for
payment of all service fees identified on the Service Fee Directory maintained by the
Commonwealth of Virginia. Billing is submitted monthly for services specified.
b. Parents of publically funded students will not be charged for any services related to the
Service Plan or IEP.
c.
Parent’s insurance of publically or privately funded students will not be charged for any
services related to the Service Plan or IEP unless specifically authorized by the parent.
d. Parents of privately funded student will not be charged for any services not rendered in
accordance with the Placement Agreement.
e. A Financial Agreement is attached (Attachment A) and incorporated in the Placement
Agreement by reference.
TIMBER RIDGE SCHOOL
Form No. 2210.5
2210.6
Placement
PlacementAgreement:
Agreement
Academic Page
Day School
3 of 3
Page 3 of 5
Policies, Regulations, and Notices
Last Revision: 5/7/14
9.
DISCHARGE.
a.
TIMBER RIDGE SCHOOL shall discharge the child at the time agreed upon or give the
Custodian and/or Sponsor Agency two (2) weeks notice if TIMBER RIDGE SCHOOL
believes that it is in the best interests of the child or TIMBER RIDGE SCHOOL to be
discharged prior to the agreed-upon time.
b.
In the event that the child presents a clear and present danger to the health, safety, or well
being of himself or other children in residence, TIMBER RIDGE SCHOOL may discharge the
child or make other arrangements for temporary placement of the child in a setting approved
by the Custodian, giving the Custodian twenty-four (24) hours notice.
c.
The Custodian agrees to give two (2) weeks written notice prior to permanent removal of the
child from TIMBER RIDGE SCHOOL, except when TIMBER RIDGE SCHOOL agrees to a
shorter notification in writing.
This agreement shall be in effect until
agreement.
In witness thereof we have set our hands and seals this
or until terminated as stipulated in this
day of
20
Signature of Parent or Legal Guardian
Date
Signature of Timber Ridge School Representative
Date
Agency Authorization
Date
.
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.5
2210.6
Placement
PlacementAgreement:
Agreement
Academic Page
Day School
4 of 3
Page 4 of 5
Last Revision: 5/7/14
Attachment A: FINANCIAL AGREEMENT
This agreement delineates the financial arrangement between the PLACING AGENCY and the LEARY
EDUCATIONAL FOUNDATION (LEF) doing business as TIMBER RIDGE SCHOOL who agree to the
placement and care of a child.
1.
The PLACING AGENCY, _________________________________________________, agrees to
reimburse LEARY EDUCATIONAL FOUNDATION (LEF) for the education and care of
___________________________________________________. (Name and birth date of child)
2.
th
The rate per day is based on the table below. This agreement is valid through JUNE 30 , 2015.
Rate Structure 7/1/14 – 6/30/15
SERVICE/DESCRIPTION
UNITS OF SERVICE (Hourly/Monthly or
Daily)
EDUCATION (Academic Day School)
Education: (per school day)
Daily
# School days per week = 5
Total schools days/year = 235
3.
RATE
FOR
ELIGIBLE
SERVICES
184.98
TOTAL EDUCATION RATE
Daily
184.98
ADDITIONAL SERVICES AS
AGREED UPON
Counseling (Individual/Family)
Group Sessions
Tutoring/ESL
Speech Therapy
Occupational Therapy
K2 or Additional Drug Testing
Translating Services
Hourly
Hourly
Hourly
Hourly
Hourly
Per Test
Hourly
99.47
60.00
26.00
100.00
100.00
30.00
65.00
The PLACING AGENCY agrees to send payment to LEARY EDUCATIONAL FOUNDATION within
45 days of receipt of correct invoice. Remit payment to TIMBER RIDGE SCHOOL, P.O. Box 3160,
Winchester, VA 22604.
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.5
2210.6
Placement
PlacementAgreement:
Agreement
Academic Page
Day School
5 of 3
Page 5 of 5
Last Revision: 5/7/14
4.
LEARY EDUCATIONAL FOUNDATION will invoice the PLACING AGENCY within 15 days after
each month end. All expenses invoiced must be pre-authorized by the PLACING AGENCY.
______________________________________________
______________
Signature of LEARY EDUCATIONAL FOUNDATION Representative
Date
_____________________________________________
______________
Signature of PLACING AGENCY Representative
Date
TIMBER RIDGE SCHOOL
Form No. 2112.2
Policies, Regulations, and Notices
Permission to Administer Standing Medical Orders
Last Revision: 2/6/13
Page 1 of 1
Student:
Allergies:
STANDING MEDICAL ORDERS
MEDICATION
EPIPEN
0.3G/INJECTION
Intra Muscular Injection
DIPHEN (BENADRYL)
25MG/TAB
(Diphenhydramine)
CHLORPHEN
4MG/TAB
(Chlorpheniramine)
SUDANYL PE
5MG/TAB
(Phenylephrine HCl)
DIAMODE
2MG/TAB
(Loperamide HCl)
ADDAPRIN (IBUPROFEN)
200MG/TAB
(Ibuprofen)
MYLANTA
200MG/5ML
(Liquid Antacid)
COUGH SYRUP
200MG/10ML
(Guaifenesin Syrup)
NON-ASPIRIN (TYLENOL)
325MG/TAB
(Acetaminophen)
INDICATION
INSTRUCTIONS
Severe Bee Stings & Allergic Reaction - Tightness in throat,
nausea, difficulty breathing, or severe swelling
Follow instructions on syringe, inject epinephrine, 0.3mg and then
CALL 911, notify doctor.
Mild Bee Stings & Allergic Reaction – Swelling around sting
site, itchy skin, or hives
If not improved after 12 hours, notify doctor.
“Cold Symptoms” – Watery Eyes, Runny Nose, Mild Cough
If not improved within 3 days, notify doctor.
Take 1-2 Capsules by mouth every 6 hours PRN for allergic
reactions.
Nasal Congestion, Sinus Congestion
If not improved within 3 days, notify doctor.
Take 2 Tablets by mouth every 4 hours - not to exceed 8 tablets
in 24 hours.
If fever or pain is persistent, notify doctor.
Take 2 Tablets by mouth initially, then 1 Tablet following each
stool - not to exceed 4 tablets in 24 hours.
If fever, pain or diarrhea is present after 4 hours, notify doctor.
TAKE AS FOLLOWS WITH REFERENCE TO THE PAIN SCALE:
RATING OF 0 TO 2 – 200MG EVERY 4-6 HOURS PRN
RATING OF 3 TO 5 – 400MG EVERY 4-6 HOURS PRN
RATING OF 6 TO 7 – 600MG EVERY 6 HOURS PRN
RATING OF 8 TO 10 – 800MG EVERY 8 HOURS PRN
DO NOT EXCEED 12 TABLETS OR 2400MG IN 24 HOURS
Shake Well. Take 2-4 Teaspoons by mouth between meals –
PRN.
Diarrhea – Watery loose stool.
If not improved after 4 hours, notify doctor.
Muscle Discomfort/Aches/Sprains
If pain persists after 3 days or there is limitation of movement,
notify doctor.
Occasional Indigestion or Heartburn
Cough
If productive cough or fever is present, notify doctor.
Fever (Above 99°F), Body Aches, & Headache
If mild or low grade fever lasts more than 3 days, notify doctor.
Take 1 Tablet by mouth every 4-6 hours PRN.
If fever, pain, or persistent cough is present, notify doctor.
Take 2-4 Teaspoons by mouth every 4 hours – PRN.
If cough is of whooping or barking nature OR if sputum is blood
tinged, brown or bright red, notify doctor.
Take 2 Tablets, 325mg, by mouth every 4 hours – PRN.
For elevated temperature greater than 103°F, notify doctor OR
seek Urgent Care/Emergency Room evaluation.
Physician Signature:
Date:
Legal Guardian Signature:
Date:
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2114.1
Rotz Pharmacy - Resident Info Form
Last Revision: 2/7/12
Page 1 of 2
RESIDENT INFORMATION FORM FOR ROTZ PHARMACY
1.
2.
3.
4.
Complete Page 1 AND Page 2.
Attach written prescriptions from the doctor.
Attach clear copies of applicable insurance cards (front AND back).
Mail to Rotz Pharmacy one week prior to Timber Ridge School arrival.
Resident Name:
Date of Birth:
SSN:
Location – Intake Unit:
List All Drug Allergies:
List Current Diagnoses/Major Medical Conditions:
Current Medications: Please provide a list of all medications the student is to receive at
the time of his admission to Timber Ridge School. This includes PRN (occasional-asnecessary) AND over-the-counter medications. Please attach written prescriptions from
the doctor for each medication.
List Medication Name, Strength & Directions:
Rotz Pharmacy – 1338 Amherst Street – Winchester, VA 22601
Fax: 540-665-2060 – Voice Message: 540-662-8312
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2114.1
Rotz Pharmacy - Resident Info Form
Last Revision: 2/7/12
Page 2 of 2
RESIDENT INFORMATION FORM FOR ROTZ PHARMACY
Insurance Policy Holder Information
(Please print or type)
Primary Insurance
Last Name:
First:
Social Security No.:
Middle Initial:
Birth date:
Street or P.O. Box Address:
City:
State:
Zip:
Home Phone No.:
Work Phone No.:
Cell Phone No.:
E-Mail:
Insurance Card: ID No.:
(Attach card copy front AND back)
Group No.:
Secondary Insurance
Last Name:
First:
Social Security No.:
Middle Initial:
Birth date:
Street or P.O. Box Address:
City:
State:
Zip:
Home Phone No.:
Work Phone No.:
Cell Phone No.:
E-Mail:
Insurance Card: ID No.:
(Attach card copy front AND back)
Group No.:
TIMBER RIDGE SCHOOL
Form No 2114.2
Medication Agreement Form
Policies, Regulations, and Notices
MEDICATION AGREEMENT
STUDENT’S NAME:
Birth date:
The following guidelines govern the administration of medication to students at TIMBER RIDGE SCHOOL
in accordance with the licensing standards required by the Commonwealth of VA and Timber Ridge
School licensing requirements, as determined by the Coordinator of Health Services.
OVER-THE-COUNTER AND PRESCRIPTION MEDICATIONS
These may be administered to students ONLY as written by a Licensed Physician. This written order
(prescription) must be on file at Timber Ridge School and at the designated Pharmacy. See attached
Form No. 2114.1 – Designated Pharmacy Resident Information Form. The pharmacy will provide Timber
Ridge School with a copy of the prescription. Approved Over-The-Counter medications and indications for
use are listed on the Standing Medical Orders form (Form No. 2112.2) and are available for review by
staff and guardians (upon request). Any change to this listing of Over-The-Counter preparations requires
a written order by the Physician.
For the safety of students and staff, medications should be unit dose packaged by a Licensed Pharmacy.
Due to the campus style setting of Timber Ridge School, the unit dose packaging system must allow for
medication administration from various on and off campus locations, at various times of the day and
during home visitations. Systems such as the Tear-Off Bubble Packs or the Sealed Envelope styles are
best. A 32 day supply of each medication is adequate.
For students planning to attend Timber Ridge School, written prescriptions should be sent to the
designated pharmacy one week in advance of the admission date. Student identification information and
all prescription insurance information on Form No. 2114.1 – Designated Pharmacy Resident Information
Form MUST be included. This is the responsibility of the guardian of the student, in cooperation with the
funding/placement agency.
Students lacking any required documentation or above conditions of medication packaging risk a delay of
medication administration for several hours, days or extended period of time.
/
Staff Member
Date
Admissions, Health Services or Designee
/
Registered Nurse
Date
Health Services Coordinator or Designee
/
Signature of Parent or Guardian - Date
/
Signature of Placing Agency Personnel - Date
Date Issued: September 20, 2006
Date of Last Revision: September 20, 2006
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.10
Perm to Search
Page 1 of 1
PERMISSION TO SEARCH
STUDENT’S NAME:
Birthdate:
I hereby give permission for the staff at TIMBER RIDGE SCHOOL to conduct
physical searches of the person (to include pat downs for students assigned to the
Dedicated Substance Abuse Unit), property, and mail of the above-named child
when deemed necessary to ensure the safety and welfare of the child or of other
children at TIMBER RIDGE SCHOOL.
Date
Signature of Parent or Guardian
NOTE: To ensure the safety and welfare of students at TIMBER RIDGE
SCHOOL, certain items are prohibited. These include illicit drugs, weapons, and
combustible materials. It has been our experience that at times some of our
students, either willfully or unknowingly, will bring some of these items on campus.
Physical searches will be conducted only upon the student's departure for or return
from a home/community visit or when there is reason to believe that the student is
in possession of prohibited items.
If a student has successfully brought contraband onto campus, or if he is highly
suspected, a more thorough search as defined in our regulation, R-2330 – Search
and Seizure, will be initiated. An Individual Behavioral Intervention Plan (IBIP) will
support this and you will be notified.
Date of Last Revision: 2/21/2014
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.11.A
Permission for Medical Treatment
Last Revision: 7/1/2014
PERMISSION TO SECURE MEDICAL/DENTAL CARE
STUDENT’S NAME:
Birth date:
_____
Social Security No.:
To Whom It May Concern:
The above named child is a student enrolled at TIMBER RIDGE SCHOOL. In the event of
illness or injury, you are authorized to secure or give medical, dental care, or necessary
immunizations. I agree and understand Leary Educational Foundation is not responsible for the
cost of this care. I further understand that I will be responsible for all costs incurred and will
promptly pay bills for medical and dental care. If your child is covered by Virginia Medicaid
Insurance, Timber Ridge School must have a contract with the Provider and issue a referral slip
or Medicaid will not pay the service claim and you would be liable for payment.
_____
Date
Signature of Parent or Legal Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.11.B
Health Service Provider Selection
Last Revision: 7/1/2014
SELECTION OF HEALTH SERVICE PROVIDERS
STUDENT’S NAME:
Birth date:
_____
Social Security No.:
Please choose below whether you elect Timber Ridge Schools’ or YOUR Family
Physician/Dentist to provide these services:
Medical Providers for Timber Ridge School:
____VIRGINIA: Amherst Family Practice
____WEST VIRGINIA:
William Bender, MD
Pam Quarantillo, MD
1867 Amherst Street
81 War Memorial Drive
Winchester, VA 22601
Berkeley Springs, WV 25411
Phone: 540-667-8724
Phone: 304-258-8805
Dental Providers for Timber Ridge School:
_ __ VIRGINIA:
_ __ VIRGINIA:
Kool Smiles
William Stiebel, DSS
2065 S. Pleasant Valley Road 1021 Aylor Road
Winchester, VA 22601
Stephens City, VA 22655
Phone: 540-931-0300
Phone: 540-869-2737
____WEST VIRGINIA:
Thomas Leslie, DDS
345 Concord Avenue
Berkeley Springs, WV
25411
Phone: 304-258-2291
Psychiatrist Provider for ALL Timber Ridge School:
____Don D. Lee, MD, MS
123 Amherst Street
Winchester, VA 22601
Phone: 540-662-0991
If you prefer to have your Home Physician or Dentist provide care, please provide the
information below.
____ Home Physician:
Phone No.
_____
Address:
____ Home Dentist:
_____
Phone No.
_____
Address:
_____
------------------------------------------------------------------------------------------------------------------------------____ Medical care and treatment will be provided by our family physician/dentist during scheduled home/community
visits at the approximate anniversary time of admission. In keeping with state regulations, a copy of the medical
report will be sent to Timber Ridge School.
____ I wish to have LEARY EDUCATIONAL FOUNDATION, INC., secure medical/dental care for the above named
child. I agree and understand that Leary Educational Foundation, Inc. is not responsible for the cost of this care. I
further agree that I will be responsible for all costs incurred and will promptly pay bills for medical/dental care as soon
as they are forwarded to me. If your child is covered by Virginia Medicaid Insurance, Timber Ridge School must have
a contract with the Provider and issue a referral slip or Medicaid will not pay the service claim and you would be
liable for payment.
_____
Date
Signature of Parent or Legal Guardian
TIMBER RIDGE SCHOOL
Form No. 2210.11.C
Health Insurance Information
Last Revision: 8/20/13
Policies, Regulations, and Notices
Student Health Insurance Information
Please complete the following important information along with front and back copies of insurance cards to
include prescription, dental and eye care cards. If insurance coverage changes, please notify Timber Ridge
School as soon as possible.
AUTHORIZED PERSON'S SIGNATURE if Timber Ridge School provides services that are eligible for
insurance reimbursement, I authorize the release of any medical or other information necessary to process
insurance claim of behalf of the student. I hereby authorize Timber Ridge School to apply for payment of
benefits on my behalf for covered services rendered by Timber Ridge School for such services.
Date
Signature
ABOUT STUDENT:
STUDENT NAME (Last, First, Middle Initial)
Birth date:
ABOUT INSURANCE:
MEDICAID:
INSURED’S I.D. NUMBER
INSURED’S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL)
INSURED’S ADDRESS (CITY, STATE ZIP)
NON MEDICAID INSURANCE:
INSURANCE CARRIER NAME & GROUP/POLICY #
INSURED’S I.D. NUMBER
INSURED’S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL)
INSURED’S ADDRESS (CITY, STATE ZIP)
INSURED’S DATE OF BIRTH
PRESCRIPTION PLAN CARRIER
INSURED’S GENDER
MALE [ ]
FEMALE [ ]
DENTAL PLAN CARRIER
INSURED EMPLOYER’S NAME
EYE CARE PLAN CARRIER
OTHER NON MEDICAID INSURANCE:
INSURANCE CARRIER NAME & GROUP/POLICY #
OTHER INSURED’S I.D. NUMBER
OTHER INSURED’S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL)
OTHER INSURED’S ADDRESS (CITY, STATE ZIP)
INSURED’S DATE OF BIRTH
INSURED’S GENDER
MALE [ ]
FEMALE [ ]
INSURED EMPLOYER’S NAME
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.12
Perm for Field Trips
Page 1 of 1
PERMISSION FOR FIELD TRIPS
STUDENT’S NAME:
Birthdate:
I hereby give permission for the above-named child to participate in field trips
planned and conducted by the staff at TIMBER RIDGE SCHOOL at various times
throughout the year.
Date
Signature of Parent or Guardian
NOTE: One of the outstanding features of the program at TIMBER RIDGE
SCHOOL is the overnight field trip program for students under the supervision of
our staff. TIMBER RIDGE SCHOOL also schedules activities throughout the year,
such as class picnics, club activities, rafting, canoeing, swimming, and organized
sports. Participation in this program, and your permission for the child's
participation, is required for admission.
Date of Last Revision: November 17, 2006
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.13
Perm for Media Release
Page 1 of 1
PERMISSION FOR MEDIA RELEASE
STUDENT’S NAME:
Birthdate:
Subject to his agreement to participate, I hereby give permission for the abovenamed child to be photographed, interviewed, and/or taped by TIMBER RIDGE
SCHOOL as well as other individuals or agencies that have met the requirements
of TIMBER RIDGE SCHOOL. I further agree that these photographs, interviews,
and/or tapes may be used in school or other publications (including news media).
Date
Signature of Parent or Guardian
NOTE: Photographs, interviews, audiotapes, films, and video tapes have proven
very useful in explaining the need for continued public support of our program. A
student will not be involved in any of these activities without his personal consent.
The requirements of TIMBER RIDGE SCHOOL do not permit the personal
identification of any student except when the activity focuses on outstanding
accomplishments of the student, such as athletic performance or awards. A
complete file of all media releases and coverage is available for your review.
Date of Last Revision: November 17, 2006
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.14
Perm to Swim
Page 1 of 1
PERMISSION TO SWIM
STUDENT’S NAME:
Birthdate:
Does the above-named child know how to swim?
YES
NO
The above-named child has my permission to participate in swimming lessons
and/or to participate in water sports as planned, conducted, and supervised by the
staff at TIMBER RIDGE SCHOOL.
Date
Date of Last Revision: November 17, 2006
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Form No. 2210.15
Perm for Correctional Visits
Page 1 of 1
Policies, Regulations, and Notices
PERMISSION TO VISIT CORRECTIONAL FACILITIES
STUDENT’S NAME:
Birthdate:
On occasion throughout the year, we take groups of students to visit local penal
institutions. The escorted tour of the facility is conducted by the correctional
facility staff and prisoners. This is strictly an educational effort to ensure that
students clearly understand the realities of prison life. Our efforts are directed at
encouraging the students to adopt a non-criminal life style.
Just prior to the visit to the correctional center, the date of the activity will be
communicated to you by your son's case manager.
Does the above-named student have your permission to participate in visits to
correctional facilities planned and supervised by the staff at TIMBER RIDGE
SCHOOL?
YES
Date
Date of Last Revision: November 17, 2006
NO
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.16
Perm for Religion
Page 1 of 1
PERMISSION TO PARTICIPATE IN RELIGIOUS ACTIVITIES
STUDENT’S NAME:
Birthdate:
Does the above-named child have your permission to participate in religious
activities while enrolled at TIMBER RIDGE SCHOOL?
YES
NO
If "YES", is this permission limited by the specification of any religion or
denomination?
YES
NO
If "YES", please specify the limitations below. If "NO", please write "NONE."
EXAMPLE: "May only attend Methodist services."
Please be advised that TIMBER RIDGE SCHOOL cannot follow any religious
dietary restrictions relating to the preparation of food. To the degree possible,
alternative foods will be served to meet any religious restrictions prohibiting the
consumption of certain foods. Please identify these below:
The above named child is forbidden by religious restrictions from consuming the
following foods:
Date
Date of Last Revision: November 17, 2006
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Form No. 2210.17
Perm for Camping
Page 1 of 1
Policies, Regulations, and Notices
PERMISSION TO ATTEND CAMPING ACTIVITIES
STUDENT’S NAME:
Birthdate:
From time to time throughout the year, we conduct overnight camping activities
planned and supervised by the staff at TIMBER RIDGE SCHOOL. Generally, the
camping trip lasts several days. During the trips the students hike, canoe, cook for
themselves, and learn of the thrills and adventure of the great outdoors.
Just prior to each camping activity, the staff member responsible for supervision will
contact you to let you know that your son will be attending. You will also be
informed of the dates when the activity will depart and return to campus.
Does the above-named student have your permission to participate in overnight
camping activities planned and supervised by the staff at TIMBER RIDGE
SCHOOL?
YES
Date
Date of Last Revision: November 17, 2006
NO
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.18
Perm for Follow-Up
Page 1 of 1
PERMISSION TO PARTICIPATE IN FOLLOW-UP ACTIVITIES
STUDENT’S NAME:
Birthdate:
Subject to his agreement to participate, I hereby give permission for the above
named child to take part in information gathering activities following his discharge
from TIMBER RIDGE SCHOOL. I understand that this information will be used
only for the following purposes:
1. Evaluating the student’s continuing needs for support from the school;
2. Evaluating the effectiveness of TIMBER RIDGE SCHOOL in achieving its
objectives, and;
3. Providing opportunities for former students to share their experiences with
current students.
I understand that no information gathered by these activities will be released in a
personally identifiable form without my consent or as may be otherwise provided
by law.
YES
Date
Date of Last Revision: November 17, 2006
NO
Signature of Parent of Legal Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.19
Perm for Athletics
Page 1 of 1
PERMISSION TO PARTICIPATE IN COMPETITIVE ATHLETICS
STUDENT’S NAME:
Birthdate:
I hereby give my consent for the above-named child to participate in competitive
athletic activities approved by TIMBER RIDGE SCHOOL. I agree not to hold
TIMBER RIDGE SCHOOL responsible for any injury occurring in the course of
such activities to the above-named student nor for the cost of any medical treatment
necessitated by such injury. All known physical conditions which might preclude the
above-named student from participating in competitive athletic activities are listed
below.
Date
Signature of Parent or Guardian
I hereby request permission and apply for the opportunity to compete in competitive
athletic activities approved by TIMBER RIDGE SCHOOL.
Date
Date of Last Revision: November 17, 2006
Signature of Student
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.20
Perm for MCI
Page 1 of 1
PRISONERS AGAINST TEEN TRAGEDIES
MARYLAND CORRECTIONAL INSTITUTION – HAGERSTOWN, MARYLAND
Your child has been scheduled to tour the Maryland Correctional Institution Hagerstown, as part of a program for children who are at risk of entering the
criminal justice system. The Maryland Correctional Institution is a medium security
prison that houses convicted felons. The program will include a brief tour of the
facility as well as an information/education session sponsored by inmates housed in
the facility. Staff of the institution will be present the entire time.
The purpose of this program is to educate and inform children about the prison and
what it really means to be incarcerated. The goal is to discourage activities and
behavior that may lead to a criminal conviction.
Proper attire is required to enter the institution for adults and students alike.
There will be no shorts, cut-off jeans, open-toed shoes, mini skirts, or other
inappropriate clothing. Anyone not dressed properly will not be permitted to enter.
Your authorization is required prior to entry into the prison and attendance in this
program.
STUDENT’S NAME:
Birthdate:
Name of Parent/Guardian:
Placing Agency Sponsor:
I give permission for the above-named child to attend a Prisoners Against Teen
Tragedies Program at the Maryland Correctional Institution, a medium security
prison located in Hagerstown, Maryland.
Date
Date of Last Revision: 1/8/2010
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Form No. 2210.22
Perm for Drug & Alcohol
Screening
Last Review: 10/11/12
Policies, Regulations, and Notices
PERMISSION FOR DRUG/ALCOHOL SCREENING
STUDENT’S NAME:
Birthdate:
My son has a history of drug/alcohol usage. I understand the necessity of monitoring continued
use so that appropriate treatment measures may be implemented. I understand that this
monitoring may include breath analysis or urine analysis.
I have had the opportunity to review the Timber Ridge School Regulation No. 2340 on Drug Use
Screening and agree that this is the best treatment option for my son.
____ I have had the opportunity to discuss my son’s drug/alcohol history with members of his
treatment team and agree that periodic screenings are necessary for his ongoing
treatment at Timber Ridge School.
____ My son has been placed here by the West Virginia Department of Health and Human
Resources and I acknowledge that these screenings are part of his probation agreement.
____ Drug/alcohol screenings are currently a part of my son’s treatment as noted in his
Individualized Treatment Plan.
____ Drug/alcohol screenings are not currently a part of my son’s treatment but consent to
testing upon suspicion and/or allegations of use.
Date
Signature of Parent or Guardian
I have read and understand the permission granted by my legal guardian.
Date
Signature of Student
TIMBER RIDGE SCHOOL
Form No. 2210.23
Health Requirement Agreement
Page 1 of 1
Policies, Regulations, and Notices
HEALTH REQUIREMENT AGREEMENT
STUDENT’S NAME:
Birthdate:
In order to meet licensing standards required by the Commonwealth of VA, all TIMBER RIDGE SCHOOL
students’ medical records must include the following:
COMPLETE PHYSICAL EXAMINATION
This form must document vision, hearing, and communicable disease status evaluation, in addition to any other
tests deemed necessary by the physician to adequately access the student’s health. All recommendations for
special nutritional requirements, activity level restrictions, and recommended follow-up care must be
documented on this form. This exam is to be completed no more than 90 days prior to admission, or seven
days following admission, unless the student is a direct transfer from another state licensed facility whose
annual exam form is complete with the above information. TIMBER RIDGE SCHOOL Health Services
Coordinator will schedule student annual exams based on the date of this “admission” examination. A licensed
physician or designee must complete, sign, and date the form, which is provided to the students’ guardian in the
pre-admission packet. The form must be presented to TIMBER RIDGE SCHOOL at the time of admission
unless prior arrangements have been made with the TIMBER RIDGE SCHOOL Health Services Coordinator in
advance of the student’s admission.
IMMUNIZATION RECORD
A Certification of Immunization record for each student must be presented to TIMBER RIDGE SCHOOL at the
time of admission. The students’ record should clearly document receipt of all vaccinations required for the
student’s age according to the Virginia Department of Health. The current requirements are available by calling
1-800-568-1929, or viewing the Internet site http://www.vdh.state.va.us/imm/Minimumschoolregs.htm.
REPORT OF DENTAL EXAMINATION
This form provides written documentation by a licensed dentist of the required annual examination of the student
and recommended follow-up dental care. This may include specific daily oral hygiene or nutritional instructions,
plans for tooth restorations, periodic dental cleanings, or referrals to dental specialists. This form must be
completed and signed by the dentist and guardian. The completed form must be presented to TIMBER RIDGE
SCHOOL at the time of admission.
In the event the above records are not presented at the time of a students’ admission to TIMBER RIDGE
SCHOOL, the guardian must agree to pay in full and within 30 days, the costs incurred as a result of
having these services conducted by TIMBER RIDGE SCHOOL medical/dental providers.
If this is not agreeable, TIMBER RIDGE SCHOOL’s only alternative is to decline the students’ admission.
/
Director of Admissions
Date
/
Signature of Parent or Guardian - Date
Date of Last Revision: November 17, 2006
/
Coordinator, Student Health Services - Date
/
Signature of Placing Agency Personnel - Date
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.24
Perm for Internet Use
Page 1 of 1
APPROPRIATE USE OF THE TIMBER RIDGE SCHOOL
NETWORK AND INTERNET RESOURCES
PARENT/STUDENT DECLARATION OF UNDERSTANDING AND ADHERENCE
I, the parent or guardian of
(student’s name), the minor student who
has signed, along with me, this acceptable use policy, understand that my son must adhere to the terms of
this policy. I understand that access to the Timber Ridge School Network is designed for educational
purposes but will also allow my son access to external computer databases, networks, etc. that are not
controlled by Timber Ridge School. I also understand that some materials available through these external
sources may be inappropriate and objectionable; however, I acknowledge that it is impossible for Timber
Ridge School to screen or review all of the materials available through these sources. I understand that
Timber Ridge School accepts responsibility to set and convey standards for appropriate and acceptable
use to my son when he is using the Timber Ridge School Network or any other electronic media or
communications associated with Timber Ridge School.
Date
Parent or Guardian Name (Please Print)
Parent or Guardian Signature
Date
Student Name (Please Print)
Student Signature
Date of Last Revision: November 17, 2006
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.25
Perm for Volunteering
Page 1 of 1
PERMISSION TO VOLUNTEER
STUDENT’S NAME:
Birthdate:
From time to time throughout the year, some students participate in volunteer
activities and are supervised by the staff at TIMBER RIDGE SCHOOL.
Just prior to each volunteer activity, the staff member responsible for supervision
will contact you to let you know that your son will be attending. You will also be
informed of the place and date where your son will be volunteering.
Does the above-named student have your permission to participate in volunteer
activities planned and supervised by the staff at TIMBER RIDGE SCHOOL?
YES
Date
Date of Last Revision: November 4, 2008
NO
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.26
Family Participation Agreement
Last Revision: 1/17/06
FAMILY PARTICIPATION AGREEMENT
STUDENT’S NAME:
Birthdate:
It is important that you are a partner in your child’s treatment. When it is possible
and appropriate, TIMBER RIDGE SCHOOL expects that families of the students
placed with us participate in a very active and supportive manner with respect to
the treatment plan that is formulated. The intent of our combined efforts is to
maintain family connectedness, and to prepare the family for reunification at the
time of discharge. It is our collective energy on behalf of your son that can make
a difference.
We work toward this goal by asking that families participate fully during the entire
course of the treatment process. In order to meet our goal, families should:
1.
Be present on the day of ADMISSION.
2.
Attend all meetings that are scheduled to review the INDIVIDUAL
SERVICE PLAN in order to provide input and help develop the treatment
plan.
3.
Attend all FAMILY SUPPORT GROUP meetings that are conducted in or
near to your home community.
4.
Attend FAMILY COUNSELING sessions as arranged by the Clinical
Counselor responsible for providing this service.
5.
Attend all on campus FAMILY DAYS that are sponsored by the
Treatment Unit that the student is assigned to at the time of the event.
6.
Attend all STUDENT AWARDS BANQUETS scheduled throughout the
year.
Signature of Parent or Legal Guardian
Date
Family Support Group
Timber Ridge School Representative
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.27
Family Visitation & Contact Info
Last Revision: 6/21/12
Page 1 of 2
FAMILY VISITATION AND CONTACT INFORMATION
STUDENT’S NAME:
Birthdate:
TELEPHONE CALLS
The designated family phone call day is Sunday from 1:15 PM to 5:00 PM, unless other
arrangements are made with the Case Coordinator. We will call you directly and we ask
that you also plan on speaking to a staff member to get an update on your son’s
behavior. If you want to speak with a staff member at other times to get an update, it is
best to call during the Case Coordinator’s planning time which is Monday-Thursday
from 12:00 PM to 3:00 PM. As a means of teaching your son appropriate behavior while
on the phone, the staff will be monitoring the phone call. Please advise us if this is not
acceptable to you as the legal guardian.
After a student earns Level 2, is off all restrictions, and is on Group A, he is allowed to
make a second phone call. This phone call is on Tuesday and you may elect to specify
who your son may call.
CAMPUS VISITS
In order to focus on a productive transition to the Timber Ridge campus, visits by the
immediate family are discouraged during the first thirty days. The Case Coordinator is
responsible for establishing requested visits. A two week notice for your visit is
requested in order to make necessary plans. The visits occur on Saturday or Sunday
from 1:00 PM to 5:00 PM. It is preferred that your son’s Case Coordinator is on duty
during the visit so you can meet and discuss your son’s progress. Please note that this
visit may be restricted to two hours, if your son is on a restriction or in the event of
severe acting out, the visit could be cancelled. As well, if a student has had difficulty
adjusting to the program, we will discuss the need to delay a visit. Please check in with
the Campus Charge person when you arrive.
Please feel free to bring a lunch that can be consumed during the visit, however, we ask
that you do not bring junk food or other items as your son has access to purchase items
with his allowance. If you have questions about what you can bring, please call the
Case Coordinator. I am sure your son will look forward to his families’ favorite treats.
Once your son attains Level 3, he will be allowed to leave campus with you. It is
important that you check in and out with the Campus Charge person and to ask for any
medication that he may take while he is with you.
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.27
Family Visitation & Contact Info
Page 2 of 2
HOME VISITS
Students are not eligible for a home community visit until they attain Level 3. The dates
for the visits are on the Timber Ridge School yearly calendar and unless there are
special circumstances, these are the designated dates for visits. For some of the visits,
Timber Ridge School will transport your son to a designated area, close to your home.
On other visits, you will be required to transport your son from and to campus. Please
remember to always check in and out at Gordanier Hall with the Campus Charge
person. Please note that we will check all luggage and your son’s person before he
returns to the unit and he will not be allowed to get back in the car after he has been
checked in.
During the home visits, your son will have objectives that he must follow. These
objectives are intended to help you and your son. Your assistance in developing these
objectives is encouraged. During the initial home visit, temptations are great. Please do
not allow visits from old friends. We find that often old influences cause difficulty and we
require constant adult supervision. Please avoid allowing your son opportunities that
could cause difficulty.
MAIL
Your son will be allowed to send letters using Timber Ridge School’s postage. If you
would like, feel free to give him more stamps. Also feel free to send mail and packages
to your son, but please clear this with your son’s Case Coordinator and secure
permission for the content of packages to avoid sending items that may not be allowed.
Please write down any person that your son CANNOT have contact with:
Signature of Parent/Legal Guardian
Date
Signature of Case Manager
Date
(not required for Academic Day School)
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.28
Code of Ethics and Mutual Responsibilities
Page 1 of 3
CHILDREN’S RESIDENTIAL FACILITIES AGREEMENT
Code of Ethics and Mutual Responsibilities
Child’s Name:
Date of Birth:
___
Medicaid #:
Date of Placement:
___
This Children’s Residential Facilities Agreement: Code of Ethics and Mutual Responsibilities (as required
by Code of Virginia §§ 63.2-900 and 63.2-902) is not inclusive of all ethical standards or responsibilities,
but rather a minimum set of expectations provided to guide the partnership between the children’s
residential facility and the placing agencies serving children in the Virginia foster care system. It is
understood that additional expectations for the care of the child will be outlined in other documents such as
the foster care service plan, child specific addenda, financial agreements and/or other contractual
documents.
This agreement is entered into on behalf of ____________________________ (child's name) and is an
agreement between _____________________________________________ (name of the children's residential
facility [CRF]) and ___________________________________________________ (name of the placing
agency, either local department of social services [LDSS] or licensed child placing agency [LCPA]). This
agreement shall be signed on or before the child is placed in the CRF and remains in effect until the child leaves
the CRF. In signing this agreement, all parties accept their responsibility to interact with respect and fairness
and to work toward developing and maintaining a positive working relationship.
The following principles are taken from the Virginia Children’s Services Practice Model and are central to
the service delivery partnership and relationships. We believe:
1.
2.
3.
4.
5.
All children and youth deserve a safe environment.
In family, child, and youth-driven practice.
Children do best when raised in families.
All children need and deserve a permanent family.
In partnering with others to support child and family success in a system that is family focused, child-centered,
and community based.
6. How we do our work is as important as the work we do.
As permanency team members, we agree to abide by this Code of Ethics and Mutual Responsibilities Agreement to the
best of our ability.
CODE OF ETHICS
1. Provide a safe, secure and stable environment that is nurturing, structured and free from corporal
punishment, and from abuse and neglect.
2. Model healthy, normative and appropriate behaviors.
3. Promote and support positive relationship development for the child.
4. Support progress toward achieving the permanency goal identified for the child.
5. Promote self-respect by providing guidance and activities that respect culture, ethnicity, and spiritual
preferences and that are consistent with the CRF’s policy.
6. Support the child, as his capability, functioning, and CRF service plan allow, in his development of selfsufficiency and his acquisition of responsible behaviors.
7. Grow through skill development, role clarification, and participation in training.
8. Practice honest and respectful communication with a focus on the child’s best interests and unique needs.
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.28
Code of Ethics and Mutual Responsibilities
Page 2 of 3
Child’s Name:
Date of Birth:
Medicaid #:
Date of Placement:
___
RESPONSIBILITIES
A. Mutual Responsibilities
1. Work together to meet the needs of the child.
2. Ensure the confidentiality of all information provided by following agency policy, state, and federal
laws. Share information received about the child, his parents, and/or extended family with the parties to
this agreement and, if applicable, the child’s guardian ad litem and other professionals.
3. Support the child's relationship with his birth family, including siblings, and other significant adults, as
outlined in the applicable service plan and other case records, treat and speak of them with consideration
and respect. These relationships must be determined by the service planning team to be in the best
interests of the child and will not jeopardize safety, well-being, or care as documented in the case record.
4. Support the child's participation in meetings, court hearings, and all other discussions when the child has
the ability to participate and participation would not jeopardize his safety, well-being, or care as
determined by the child’s service planning team.
5. Participate in meetings related to permanency planning. Reasonable, advance notice will be given to all
parties involved.
6. Consider additional support services and assessments in an effort to maintain this placement. Allow
sufficient time for implementation of those services/assessments before terminating this placement if it
is safe to do so. Discuss when and how to tell the child of concerns about placement change. The LDSS
or LCPA may remove the child without notice if the child’s well-being and safety are in jeopardy. If the
CRF determines that the child's behaviors jeopardize the well-being and safety of the child or others, the
CRF may discharge the child without notice.
7. Implement a working routine and urgent communication response system for relaying or discussing
information pertaining to the child.
8. Report immediately all suspected child abuse or neglect to the LDSS of the county or city wherein the
child resides or wherein the abuse or neglect is believed to have occurred or to the Child Abuse and
Neglect Hotline (1-800-552-7096).
B. LDSS or LCPA Responsibilities
1. Ensure that the signed financial agreement includes the date payments will be made.
2. Consider CRF's questions, concerns, and ideas and offer reasonable explanations if the parties disagree.
Agree not to threaten, discriminate or retaliate when decisions and practices are questioned.
C. CRF Responsibilities
1. Agree that authorized representatives of the LDSS or LCPA shall have access at all times to the child
and the facility. The CRF will release custody of the child to the LDSS’ or LCPA’s authorized
representatives whenever, in the opinion of the LDSS, LCPA or the DSS Commissioner, it is in the best
interests of the child.
2. Agree to support agency contact and visits with the child with the expectation that the LDSS or LCPA
will accommodate the schedule of the CRF, including the child’s schedule, to the degree possible.
3. Agree to inform the LDSS or LCPA of substantive changes in behavior management and circumstances
affecting the operation of the CRF, including changes made to the length and status of the license to
operate.
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.28
Code of Ethics and Mutual Responsibilities
Page 3 of 3
Child’s Name:
Date of Birth:
Medicaid #:
Date of Placement:
4. Agree to discuss any information with the LDSS or LCPA that may impact the child’s safety, wellbeing, ability to progress towards permanency, and placement stability. Information will be discussed in
accordance and compliance with laws and regulations governing CRF’s.
5. Agree that corporal punishment is prohibited and it will never be used by the CRF.
6. Agree, if the CRF is licensed by Department of Behavioral Health and Developmental Services, to abide
by “Rules and Regulations to Assure the Rights of Individuals Receiving Services From Providers
Licensed, Funded or Operated by the Department of Behavioral Health and Developmental Services.”
Routine Contact information
CRF Contact Name:
Phone Number: (
Title:
)
E-mail Address, if Available:
LDSS/LCPA Contact Name:
Phone Number: (
Title:
)
E-mail Address, if Available:
Urgent Contact Information
CRF Phone Numbers:
LDSS/LCPA Phone Numbers:
A. Weekdays: (
A. Weekdays: (
)
B. Evenings and Weekends: (
C. Holidays: (
)
)
B. Evenings and Weekends: (
)
)
C. Holidays: ( )
By signature, all parties acknowledge having read, understood, and accepted the expectations outlined in
this agreement. The LDSS or LCPA shall provide a copy of this agreement to the CRF at the time the
child is placed, at the time all required signatures are obtained and when an additional copy is requested.
LDSS or LCPA Staff
Date
LDSS/LCPA Director or Designee
Date
Created: 12/8/09
Last Revision: 6/21/12
CRF Chief Administrative Officer
or Designee
Date
(not required for Academic Day School)
TIMBER RIDGE SCHOOL
Form No. 2210.30
Permission for Influenza Vaccine
Revised date: 9/14/10
Policies, Regulations, & Notices
Permission for Influenza Vaccine
Patient History: To Be Completed by Parent or Legal Guardian
Patient Name:
(Last)
(First)
Birth Date:
/
/
Residential Student @ Timber Ridge School – Phone No. of RN: 540-888-3456, X1140
Drug Allergies:
Please read the questions below. Circle YES or NO for the person receiving the vaccine(s).
1. Has your child ever had a severe reaction to any vaccine which required medical care?
YES
NO
2. Is child allergic to Eggs, Baker’s Yeast, Streptomycin or Neomycin?
YES
NO
3. Does the child have a history of Guillain-Barre Syndrome?
YES
NO
Consent for Administration of Vaccine
I consent to, or give consent for, the administration of the Influenza Vaccine.
Signature of Parent or Legal Guardian
Influenza
Vaccine
Dose
0.5 ml
Manufacture
Date
Lot No.
Exp. Date Site
Vaccine
Administrator Signature
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.31
Behavior Support and
Management Acknowledgment
Last Review: 8/28/12
BEHAVIOR SUPPORT AND MANAGEMENT ACKNOWLEDGMENT
STUDENT’S NAME:
Birthdate:
Timber Ridge School believes in a culture that promotes respect, healing, and positive behavior,
and provides individuals with the support they need to manage their own behaviors. Timber
Ridge School has a Behavior Management System (BMS) that serves as the foundation for our
daily structure and supervision.
Timber Ridge School also uses Therapeutic Crisis Intervention (TCI) which was developed by
Cornell University and is a crisis prevention and intervention model for our program. It assists in
preventing crisis from occurring, de-escalating, potential crisis, managing acute physical
behavior, reducing potential and actual injury to young people and staff, teaching young people
positive coping skills and helps to create a learning organization.
Our behavior management system and therapeutic crisis intervention procedures are approved
by our licensing agencies.
Please sign below to confirm the Timber Ridge School behavioral support and management
procedures were reviewed with you.
Date
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.32
Permission for Participation in
Family Life Education
Last Review: 4/30/2013
Permission for Participation in Family Life Education
STUDENT’S NAME____________________________DATE____________
I hereby give permission for the above named student to participate in
Family Life Education that is part of the health curriculum offered at
Timber Ridge School. Please check below.
Family Life Education:
___General education curriculum
___General education curriculum with modifications
___Opt-out all
___Opt-out specific sections___________________________
_____________
Date
___________________________________
Parent or Legal Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.7
Perm for Medical Exchange of Info
Page 1 of 1
Last revision: 8/31/12
PERMISSION FOR MEDICAL EXCHANGE OF INFORMATION
I, the undersigned parent/legal guardian for:
STUDENT’S NAME: ___________________________ Birthdate: ____________
authorize and request that:
Facility Name
Facility Address
For Treatment Dates:
_ to
Release Records to:
Verbally communicate with :
Coordinator of Health Services
Timber Ridge School/Leary Educational Foundation, Inc.
Purpose of disclosing:
Information Requested:
_____ Discharge Summary
_____ Psychological Testing/Evaluation
_____ Social History
_____ Other ______________________
_____ Physical Examination
_____ Immunization Record
_____ Laboratory/Radiological Data
_____ Consultation ______________
I understand that no limitations are placed on dates, history of illness, or diagnostic
and therapeutic information, including any treatment for alcohol and drug abuse. I
understand what information has been requested and have been explained the
benefits/disadvantages of releasing this information. I further understand that the
provision of services is not contingent on the release of this information and I
voluntarily consent to the release of this information. This authorization is protected
by Federal confidentiality rules (42CFRII).
This authorization will expire in one (1) year on
.
Date
_____________________
Date
____________________________________
Student Signature
_____________________
Date
cc: Parent/Legal Guardian
____________________________________
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No. 2210.9
Perm to Test
Page 1 of 1
PERMISSION TO TEST
STUDENT’S NAME: _________________________ Birthdate: _____________
I hereby authorize the staff at TIMBER RIDGE SCHOOL to conduct or authorize
psychological, psychiatric, educational, and related testing or evaluations of the
above-named child. I understand that all evaluations will be conducted by qualified
personnel. I further understand that I will be informed of the results of the
evaluations and that any information resulting from the evaluations will be
maintained in accordance with the Rules and Regulations of the Virginia Board of
Education governing the management of student records.
___________________
Date
Date of Last Revision: November 17, 2006
____________________________________
Signature of Parent or Guardian
TIMBER RIDGE SCHOOL
Policies, Regulations, and Notices
Form No.2210.33
Review of Regulations Acknowledgement
Last Revision: 9/20/13
Page 1 of 1
Review of Regulations Acknowledgment
(Required for Residential and Day School programs)
STUDENT’S NAME ___________________________________________________
Timber Ridge School uses Therapeutic Crisis Intervention (TCI), which was developed by
Cornell University and is a crisis prevention and intervention model for our program. It
assists in preventing crisis from occurring, de-escalating, potential crisis, managing acute
physical behavior, reducing potential and actual injury to young people and staff, teaching
young people positive coping skills and helps to create a learning organization.
Removal to the Low Stimulus Area is an environmental intervention designed to provide a
safe environment for a student during a period of extreme behavior allowing for the
coordination of appropriate stabilization services.
Please sign below to acknowledge that you have read and are aware of the following:
o Regulation #2132 - Use of Therapeutic Crisis Intervention *
o Regulation #2302 - Removal to Low Stimulus Area *
* These regulations will be available to you at the time of admissions.
___________________________________
Signature of Parent or Guardian
_____________________
Date