Solacium Alldredge LLCADMISSION PACKET FORMS ALL FORMS MUST BE COMPLETED AND SIGNED PRIOR TO ADMISSION Admissions Agreement Financial Agreement – Exhibit A Authorization for Release of Information – Exhibit B Prescription Benefit Information – Exhibit C Medical Information ‐ Exhibit D Family / Parent Questionnaire – Exhibit E Power of Attorney – Exhibit F Release for Student School Records – Exhibit G Commitment to Therapy – Exhibit H Family Information List of Required Personal Items Elopement Description ADDITIONAL INFORMATION PLEASE BRING THE FOLLOWING ITEMS UPON ADMISSION A. B. C. D. Copy of Picture ID (Driver’s License/School ID) Copy of Student’s Social Security Card Copy of Student’s Birth Certificate Copy of Immunization Record E. Official School Transcripts F. Copy of Insurance Card G. Custody/Court Documents (if applicable) APPLICATION & PAYMENT A Security Deposit of $750.00 is required to reserve your child’s spot in the program; this deposit will be credited toward the first month’s tuition. Alldredge Academy must receive the initial tuition payment of the first twenty eight(28) days upon Student admission. (See Financial Agreement – Exhibit A) Student Travel Arrangements: Students must arrive at the Wilderness Office in Davis, WV by 1:30 pm on Wednesday. PLEASE CONTACT ADMISSIONS WITH CONFIRMED TRAVEL ARRANGEMENTS. If your child needs to come early for any reason, we can provide supervised accommodations for them for up to two weeks prior to the specific enrollment date at a cost of $350.00 per day. How did you hear about Alldredge? _________________________________________________________ Name of referring Family, Professional or Educational Consultant:_____________________________________________ Address:___________________________________________________________________________________________ Phone: _________________________ Fax:________________________ Email: ________________________________ For Office Use Only: Admissions Date:__________________ Time:____________ Escorted by:___________________Discharge Date:_______________ Admissions Approval Initials:________ Date:______________ Clinical Approval Initials:________ Date:____________ AA Field Superviser Initials:_________ Date:______________ Medical Approval Initials:________ Date:____________ SOLACIUM ALLDREDGE LLC ADMISSIONS AGREEMENT AGREEMENT dated ______________________________________, between Solacium Alldredge LLC, a Delaware Corporation (hereinafter “Alldredge Academy”) and ___________________________________________________________________________________________________ (Name of Parent(s) or Guardian(s)) (hereinafter the “Sponsor”). In consideration of the mutual promises set forth in this Agreement, Alldredge Academy and the Sponsor (hereinafter the “Parties”) agree as follows: 1. The Sponsor affirms they are the legal parents or guardians of __________________________________________, whose birth date is on the _______ day of ______________ 19_______ (hereinafter the “Student”), and that he/she expressly desire to contract for her enrollment in Alldredge Academy and temporarily delegate his/her parental or guardian powers regarding care and property of the Student according to the terms of this Agreement. 2. The student will enroll in Alldredge Academy commencing on the _________ day of _________________, 20__________, continuing through the _______ day of ______________ 20_______ except as otherwise provided in this Agreement. In the event the Student attains age eighteen (18) years before completion of the agreed enrollment contract period, the Student’s enrollment will end on their eighteenth (18) birthday unless the Student agrees, in writing, to continue his/her enrollment. 3. The Parties agree that Alldredge Academy has the right to discharge the Student for whatever reason, as determined in the sole discretion of Alldredge Academy, including but not limited to based on a determination (a) that the Student is not responding to treatment, (b) that continued placement in the facility is not in the best interest of the Student, the Sponsor and/or Alldredge Academy or (c) that the Student does not meet admission criteria after the initial assessment. Except as otherwise provided for herein, in any such case, Alldredge Academy agrees to notify the Sponsor of such intent to discharge at least five (5) days prior to discharge. 4. In the event Alldredge Academy recommends early discharge of the Student due to clinical readiness, as determined in the sole discretion of Alldredge Academy, his/her enrollment will end on the date mutually agreed upon by the Sponsor and Alldredge Academy. 5. Alldredge Academy will notify the Sponsor as soon as reasonably possible in the event of an emergency discharge or transfer due to health or safety reasons, i.e. medical instability, as determined in the sole discretion of Alldredge Academy. Continued enrollment will be based on the clinical judgment of Alldredge Academy. At the time Alldredge Academy relinquishes physical custody of the Student to the Sponsor or Sponsor’s agent, for reasons set forth in this paragraph 5, no additional treatment fees/charges will be incurred. 6. In the event of an emergency due to an Act of God or facility disaster (i.e. earthquake, fire, etc.) Alldredge Academy will continue to care for the student but will not be held legally liable for any consequences from such emergency. Alldredge Academy will notify the Sponsor as soon as reasonably possible after the occurrence of the emergency and the Sponsor will arrange for discharge and/or transfer within twenty‐four (24) hours of such notification. 2 _______Initials 7. 8. 9. In the event of the Student’s abandonment of Alldredge Academy’s program, Alldredge Academy will contact the Sponsor as soon as reasonably possible. Student discharge will become official after seventy‐two (72) hours from the time of the abandonment. The Sponsor may work with the Alldredge Academy’s Admissions Director to determine the possibility of re‐admission. The Sponsor remains financially responsible for all fees until the Student’s abandonment becomes official. The Sponsor may withdraw the Student from Alldredge Academy at any time. However, should the Sponsor elect to withdraw the Student prior to the end of the contract enrollment period (as set forth in Exhibit A attached hereto), the Sponsor shall provide Alldredge Academy with written notice of the intent to withdraw the Student no less than seven (7) days prior to withdrawal. If written notice is not received, Alldredge Academy reserves the right to charge fees for seven (7) days. The Sponsor will be responsible for payment through the date of such discharge. Upon execution of this Agreement by the Parties and admission of the Student, as determined in the sole discretion of Alldredge Academy, Alldredge Academy agrees to provide the following services: room and board, counseling and therapeutic services for the Student, educational and academic services, laundry services, nursing services, personal Student supervision, supervised use of recreational equipment and facilities, supervised work experience as appropriate and/or necessary, and bookkeeping. 10. In consideration of all services performed, the Sponsor shall pay Alldredge Academy the negotiated tuition as outlined in the signed Financial Agreement attached hereto as Exhibit A. The fees shall be due on the first day of each phase. Upon admission, the Sponsor shall pay for the first twenty eight(28) days of treatment. The Sponsor shall be billed prior to the first of each remaining phases. Monthly tuition payments are considered number of days the Student will reside at Alldredge Academy. Alldredge Academy shall charge the daily enrollment rate for both admission and discharge dates. 11. The Sponsor, by execution of this Agreement, gives informed consent for the Student to participate in all programs and activities of Alldredge Academy including but not limited to the services set forth above in paragraph 9, educational/therapeutic programs, work projects, testing and evaluations (including but not limited to pregnancy, drug and alcohol tests and psychological examinations), training programs, snow skiing, snow tubing, cross country skiing, mountain biking, river rafting (Class 3 or lower), swimming, ropes course, and other various forms of recreation and athletics. 12. Sponsor acknowledges that in the course of enrollment of the Student, it may be necessary to restrain, confine and/or perform searches of the Student and/or the Student’s personal belongings. The Sponsor hereby specifically consents to such activities as deemed necessary in the sole discretion of Alldredge Academy. 13. Sponsor specifically consents to Alldredge Academy release of medical or other personally identifying information about the Student during the course of the Student’s enrollment, as deemed necessary by Alldredge Academy in its sole discretion. Sponsor agrees to execute the “Authorization for Release of Information” attached hereto as Exhibit B as requested by Alldredge Academy. 14. In connection with its treatment program, Alldredge Academy may deem it appropriate to photograph or videotape its students. Accordingly, Sponsor hereby specifically consents to Alldredge Academy photographing and videotaping of the Student in connection with the services provided by Alldredge Academy. Any such photographs and/or videos shall be the sole property of Alldredge Academy. 15. The Sponsor is responsible for any expenses not specifically included in this Agreement incurred by the Student including but not limited to: clothing, airline tickets, escort fees (if applicable), other forms of commercial transportation (including reasonable costs of ground transportation) and staff escorts not associated with standard activities and programs of Alldredge Academy. 3 _______Initials 16. The Sponsor shall be responsible for all medical and dental expenses incurred by the Student during his/ her enrollment at Alldredge Academy. The Sponsor shall be responsible for payment of expenses for prescription medications and in‐take physicals. 17. The Sponsor acknowledges the risks inherent in the custodial care and services and activities provided by Alldredge Academy and hereby expressly accept and assume all risks that are or may be associated with the custodial care and the services and activities provided by Alldredge Academy. The Sponsor further acknowledges that Alldredge Academy is not designed or staffed to prevent student abandonment and is not liable in any way if the Student abandons Alldredge Academy program. 18. The Sponsor shall be responsible and pay for any property damage and/or injuries initiated or sustained by the Student or damages to the Student’s property while the Student is in the custody of Alldredge Academy or during any abandonment of the program by the Student. This includes but is not limited to damage and/or injuries to Alldredge Academy facilities, Alldredge Academy employees, other students, and/or any visitors or contracted professionals. 19. In consideration of the enrollment of the Student and the services provided by Alldredge Academy the Sponsor individually (and jointly and severally as the case may be), and on behalf of the Sponsor’s executors, administrators, heirs, next of kin, representatives, successors and assigns, agrees to: (a) waive, release and discharge Alldredge Academy and its successors, assigns, affiliates, employees, managers, members, officers, directors, attorneys, agents and other representatives (“Released Parties”) from any and all liability for the death, disability, illness or personal injury of the Student, or damage or theft of the Student’s property, occurring while the Student is enrolled with Alldredge Academy or during any period after the Student has abandoned Alldredge Academy’s program, whether occurring on or off the Alldredge Academy’s Campus’, and covenants not to sue any of the Released Parties with regard to the same; and (b) protect, defend, hold harmless and indemnify each of the Released Parties from and against any and all claims, actions, causes of action, proceedings, suits, costs, liabilities, damages, and expenses, whether known or unknown (including, but not limited to, all direct, special, incidental, exemplary and consequently damages, and losses of any kind and attorneys’ fees) based upon, resulting from and/or relating in any way to the Student’s enrollment with Alldredge Academy, including but not limited to any abandonment of Alldredge Academy’s program by the Student. 20. Alldredge Academy contracts directly with the Sponsor and does not accept responsibility associated with the Student’s or Sponsor’s insurance company or school district; this includes but is not limited to verification of insurance benefits, admission or medical treatment pre‐certification, or billing to the Student’s or Sponsor’s insurance company(s). 21. The Sponsor agrees to pay collection costs for any amount due under this Agreement, including but not limited to reasonable attorney and court fees. 22. Alldredge Academy will not release the official transcripts of the Student’s academic credits until all amounts due Alldredge Academy under this Agreement have been satisfied in full. 23. By executing this Agreement, Sponsor submits to the jurisdiction of the State of West Virginia in any dispute between the Parties arising out of or relating to this Agreement. The Parties acknowledge that this Agreement constitutes a business transaction subject to the provisions of the laws of the State of West Virginia. Moreover, the Parties agree that the laws of the State of West Virginia shall govern this Agreement. Failure of the Parties to enforce any term or provision of this Agreement shall not constitute or be construed as a waiver of such term or provisions or right to enforce the same. If any provision of the Agreement is construed to be overbroad as written, the remaining provisions shall remain enforceable. 4 _______Initials 24. The Sponsor, simultaneous with the execution of this Agreement, shall appoint Alldredge Academy as the Student’s true and lawful attorney for the purpose of providing custodial care and educational and clinical services, and shall delegate and assign to Alldredge Academy all of the Sponsor’s powers, relating to the care, custody and property of the Student, as permitted by law, during the contract period of enrollment. The Sponsor must sign Exhibit D “Power of Attorney” attached hereto on or before the admission date. 25. The Power of Attorney referenced in paragraph 26 shall be effective for six (6) months as prescribed by West Virginia law. As applicable, one (1) month prior to the expiration of the Power of Attorney, Alldredge Academy shall request the Sponsor execute another Power of Attorney so that a Power of Attorney will be in effect for the duration of the Student’s enrollment at Alldredge Academy. Continued Student enrollment is contingent upon the existence of a valid Power of Attorney. 26. In order for the Student to be admitted to Alldredge Academy, unless otherwise agreed to by Alldredge Academy, the Sponsor must execute the “Request for Student School Records” attached hereto as Exhibit E and the “Commitment to Therapy” attached hereto as Exhibit F. Additionally, the Sponsor shall sign the “Interstate Compact Placement Request” attached hereto as Exhibit G if the Student’s primary residence is outside the State of West Virginia. 27. The Sponsor hereby acknowledges that the Sponsor has read this Agreement and understands and consents to its provisions. This Agreement (and all documents (a) referenced herein, (b) accompanying this Agreement or attached hereto as exhibit, or (c) included as part of the application packet) constitutes the entire Agreement between the Parties, except as otherwise noted. All obligations of the Sponsor under this Agreement are joint and several, as the case may be. IN WITNESS WHEREOF, the Parties have executed this Agreement as of the _____ day of _______________, 20___. ____________________________________________________________________________________________________ Sponsor (Father/Guardian) ______________________________________________________________________________________________________ Sponsor (Mother/Guardian) ______________________________________________________________________________________________________ Authorized Representative of Alldredge Academy 5 _______Initials Exhibit A SOLACIUM ALLDREDGE LLC TUITION FINANCIAL AGREEMENT The undersigned Sponsors agree to pay Alldredge Academy under the terms of this Tuition Financial Agreement. TUITION AGREEMENT – A Security Deposit of $750.00 is required to reserve your child’s place in the program. Payment of $ _________________ is due the first day of each phase during the contract enrollment period (as set forth below). The Sponsor agrees to pay for the first (28) days of treatment upon admission. The Sponsor will be billed 10 days prior to the next month of treatment with payment due by the day the student moves into the next phase of the program. Student’s Academic Transcripts may not be released until accounts are paid in full. Any accounts over 90 days will be placed with a collection agency for collection. The Sponsor agrees to pay Alldredge Academy for all collection costs incurred in connection with any amounts due under this Financial Agreement, including but not limited to reasonable attorneys’ fees and court costs. All obligations of the Sponsor hereunder shall be joint and several, as the case may be. Tuition may be paid by Personal Check or Credit Card (Master Card, Visa or Am EX) I authorize payment of $_____________ to be charged to my MC, Visa, or Am EX) Credit Card # ___________________________________________________________ Expiration Date: _________________ 3 Digit Sec Code: _________________ (Found on back of card above signature) Card Holder’s Name: ____________________________________________________ (PLEASE PRINT) Signature of Cardholder __________________________________________________ Sponsor (Parent or Guardian) Sponsor (Parent or Guardian) Student Program Description Enrollment Period PAYMENT SCHEDULE DATE DUE AMOUNT Signed and agreed to this ______________________________ day of __________________________________, ___________. _________________________________________ _______________________________________________ Sponsor (Father/Guardian) Sponsor (Mother/Guardian) Authorized Representative of Alldredge Academy _________________________________________ Exhibit A 6 _______Initials SOLACIUM ALLDREDGE LLC Service & Fee Schedule 1. 2. 3. Non‐refundable deposit: $750.00 is required to hold your child’s place in a group. Semester Back Program: Three months of intensive one on one counseling and group process work, two Family Workshops, 5 units of academic credit possible $30,500.00 Wilderness/Search and Rescue Program: 28 days of intensive one on one counseling and group process work, one Family workshop, 1.5 units of academic credit possible ‐ $12,700.00. 4. Wilderness plus Program: 56 days of intensive one on one counseling and group process work, two Family Workshops, 3.5 units of academic credit possible ‐ $22,900.00. 5. Extended Stay: $5,700.00 per month, students continue with their individual and group process work while continuing their academic curriculum. They engage in a variety of arts, sports, and adventure activities. Alldredge Academy is accredited by North Central Association Commission on Accreditation and School Improvement. 6. Program Completion Summary including recommendations for after‐program placement and counseling. We work closely with families, referring professionals and therapists to develop a plan for maintaining the progress made during the child’s participation in the Alldredge Academy’s Programs. 1. ADDITIONAL SERVICES & FEES After Care Program: eight week program following the Alldredge Academy Wilderness Plus or Semester Back Program experience. This program will provide the continuity of care in a manner that is congruent with Alldredge Academy’s mission, and assist in the transition from program to the home and or academic environment ‐ $1,500.00. After Care Plus: 12 week program incorporating a three day home visit with intense family sessions ‐ $5,900.00 2. Psycho‐educational and Projective Testing can be administered by a licensed psyhcomnitrician while a child is enrolled at Alldredge Academy. The cost will vary according to the instruments employed. A standard batter, consisting of the WISC, IV and MMPI‐A – cost is approximately $600.00. 3. Standardized Testing such as SSAT, ISEE, PSAT, SAT, ACT and the GED may be arranged through the Director of Academics. 4. High School Diploma Students who complete their high school work with Alldredge can graduate from Alldredge Academy _____________________________________ (Financial Sponsor’s Signature) Date ________________________ Prices subject to change without notice. Exhibit B 7 _______Initials SOLACIUM ALLDREDGE LLC AUTHORIZATION FOR RELEASE OF INFORMATION I, ______________________________________________________, the legal parent or guardian (Sponsor) (or the Student, if 18 or older), of ______________________________________________________ (Student), hereby authorize Solacium Alldredge Academy LLC, and the below named person/organization to exchange the Student’s (set forth above) medical and clinical information relating to dates of treatment, medical, psychological, social, psychiatric, and/or substance abuse diagnoses, treatments, prognosis, counseling, school records, and/or therapy herein contained in the patient’s medical records. FACILITY STREET ADDRESS CITY STATE, ZIP CODE PHONE NUMBER Please release the following information for the approximate Date(s) of Service: ______________________________ Discharge Summary Psychosocial History Physician Orders Psychiatric Evaluation Physician Progress Notes Consultation Reports History and Physical Examination Clinical/Nursing Staff Progress Notes Laboratory/Radiological Reports Medication Administration Records Psychological Testing Other ___________________________________ MAILING ADDRESS Alldredge Academy P.O. Box 310 Route 32, William Ave. Davis, WV. 26260 Attention: Admissions Department Phone – 304‐259‐5220 This authorization is valid one (1) year from the date signed. This consent is subject to revocation in writing by the undersigned at anytime, except to the extent that action has been taken in reliance thereon. Signed and agreed to this _______________________________________ day of _______________________________________, 20________________. ____________________________________________________________________________________________________ Sponsor (Father/Guardian) ______________________________________________________________________________________________________ Sponsor (Mother/Guardian) ______________________________________________________________________________________________________ Student (as applicable) ______________________________________________________________________________________________________ Authorized Representative of Alldredge Academy Exhibit D Exhibit C 8 _______Initials PRESCRIPTION BENEFIT INFORMATION OMNICARE PHARMACY 1401 EARL CORE ROAD, SUITE A MORGANTOWN, WV 26505 1‐800‐350‐0868 STUDENT LAST NAME STUDENT’S FIRST NAME STUDENT’S MIDDLE INIT. FACILITY Alldredge Academy PHYSICIAN’S NAME PHYSICIAN’S ADDRESS PHYSICIAN’S PHONE NUMBER PHYSICIAN’S FAX NUMBER PHYSICIAN’S EMERGENCY NUMBER/PAGER PHYSICIAN’S DEA NUMBER ADMISSION DATE STUDENT BIRTH DATE STUDENT SSN STUDENTS SEX CURRENT MEDICATIONS WITH DIAGNOSIS FOR EACH PAY STATUS INSURANCE COMPANY, ID & GROUP # (PROVIDE COPY OF FRONT AND BACK OF EACH INSURANCE CARD FINANCIAL SPONSOR OR RESPONSIBLE PARTY ADDRESS, CITY, STATE, ZIP PHONE NUMBER I, the undersigned legal parent or guardian (Sponsor) of the Student, understand and agree that I am financially responsible for the cost of all medications not covered under my prescription plan. I (Sponsor) agree to reimburse Alldredge Academy or Omni Pharmacy for the cost of medication if no prescription coverage is available. Signed and agreed to this _______________________________________ day of _________________________________________, 20____________. 9 _______Initials Exhibit D SOLACIUM ALLDREDGE LLC MEDICAL INFORMATION MEDICATIONS: Very important! Be sure to send a three month supply of required medicine in Doc‐u‐Dose packaging for the duration of the program. If your child uses an inhaler, be sure to send an adequate supply. If there are no medications, please indicate by initialing here: _________ Date ________________ List ALL medication the student is currently taking, including prescriptions and non‐prescriptions. Medication’s Name: Reason Prescribed: By What Route: Medication Name: Mg tablet (if applicable): Reason Prescribed By What Route: Medication Name: Reason Prescribed: How much: (dosage) By What Route: How Often: How much: (dosage) How often: Mg tablet (if applicable) How often: Mg. tablet (if applicable) How much: (dosage) *IF YOUR CHILD IS TAKING MEDICATION FOR ADD OR ADHD PLEASE BE INFORMED IT IS OUR POLICY THAT STUDENTS DO NOT GET THESE MEDICATIONS IN THE WILDERNESS OR VILLAGE PHASES UNLESS SPECIFICALLY ORDERED BY THE PHYSICIAN. PLEASE CONTACT THE MEDICAL COORDINATOR FOR FURTHER INFORMATION. I declare the above information is complete and correct: ______________________________ ___________ ________________________ _______ Participant (if 18 or older) Date Parent or Guardian Date WAIVER OF PHYSICAL EXAMINATON REQUIREMENT I acknowledge receiving and reading the Alldredge Academy materials. I am aware of the physical examination requirement to enroll my student in the program. In lieu of a physical examination, I waive the requirement that my son/daughter be examined by a physician prior to participating in the program. I affirm that I am unaware of any physical or medical conditions that would prevent him/her from participating in a vigorous hiking experience. I waive completely any claim against the Alldredge Academy for consequences arising from any undisclosed or unknown medical condition. I understand that there is some additional risk that my child may be hurt or harmed in some way from unknown physical conditions that may exist that I am not aware of that may be discovered during the physical examination called for in the Alldredge Academy application materials. _____________________________________ _______________________________ _______________ Signature of Parent or Guardian Printed Name of Parent or Guardian Date 10 _______Initials OMNICARE PHARMACY AUTHORIZATION INFORMATION Admit Date: ___________________________________ Facility: ALLDREDGE ACADEMY Student Name:________________________________ Male________ Date of Birth: ________________________________ Female________ SS #: _____________________________________ PAYMENT CLASSIFICATION Please check appropriate blanks: _______ Private Pay ________Prescription Insurance Coverage — Enter Name of Carrier If student has prescription insurance, please forward a copy of both the front and back of the insurance card to Omni Care Pharmacy to determine coverage. PERSON RESPONSIBLE FOR PAYMENT Omni Care Pharmacy requires a financially responsible party be on file prior to dispensing medications. By signing this form, I authorize OMNI CARE PHARMACY to furnish prescription medications and supplies for use by the above named student as ordered by the attending physician. I request that payment of authorized insurance benefits be made to Omni Care Pharmacy for any services provided. I authorize any holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits or the benefits payable for related services. I agree to make payment to OMNI CARE PHARMACY for items not covered by Insurance Agencies. I understand that Omni Care Pharmacy's statement will be sent to me each month and is payable upon receipt. NAME: ________________________________________ SS#________________________________________ Relation to Student: ______________________________________________________________ _________Self ________Spouse _________Guardian _______POA _______ Other Address:_______________________________________________________________________________________________ Telephone (day) ________________________ (evening)________________________________ Signature: ____________________________________ For: ________________________________________________ Person responsible for payment Student Date:___________ Facility Person Completing Form and Witnessing Signature: ___________________________________________________ Completed form must be sent or faxed to Omni Care Pharmacy prior to admission. Fax this page with a copy of the front and back of insurance card to Omni Care Pharmacy, Attn: Judy or Jill 800-300-1144 11 _______Initials Dear Parents: In order to provide the best possible way to administer medications in our school we are using a pre‐pack system known as “Doc.U.Dose” for supervised self‐administration (meaning we watch to make sure the medications are properly taken and swallowed.) You are free to have your local pharmacy prepare the medications using the Doc.U.Dose system. We have made arrangements to provide this service to you with a local pharmacy known as Omni Care Pharmacy. The Omni Care Pharmacy requires that the enclosed two forms be completed and forwarded directly to them with the original prescription. In the event that your insurance will not allow a prescription to be filled, the pharmacy will contact the insurance company directly for permission to fill the prescription due to your child’s enrollment. For your reference: Omni Care Pharmacy 1401 Earl Core Road, Sutie A Morgantown, WV 26505 Attn: Judy or Jill Phone: 800‐350‐0868 or 800‐455‐3080 Fax: 800‐300‐1144 or 800‐230‐3083 Please also include a copy of the Omni Care Pharmacy pages with your admissions packet. Should you have any questions or concerns please feel free to contact me. Sincerely, Alldredge Academy Medical Coordinator 304‐259‐5220 12 _______Initials MEDICAL EXAMINATION (To be completed by physician) Name of Student: _________________________ Date ___/___/____ The student named above will be participating in The Semester Back Program, an extended outdoor living and education program situated in the Canaan Valley in and around Davis, West Virginia. Participants may occasionally hike 10 or 12 miles in a day, with a pack. According to the season, the weather in this part of West Virginia can be hot and humid, or cold with wind, rain, or snow. The groups of 8 students and 3‐4 adults carry all their provisions for a 29‐day outing. The diet reflects the realities of backpacking or rafting or canoeing: lentils and beans, rice, rolled oats, powdered milk, whole wheat flour, raisins and dried fruits, vegetables, nuts, and other nutritious basic fare which is resupplied weekly. Students and staff sleep in tents, under tarps, or in shelters, as conditions dictate. Your appraisal of this studentʹs general health and physical condition will help us anticipate his or her needs and limitations at various points during the program. If you become aware of any health consideration or reason why this student should not participate in an outdoor program, please apprise us. An applicant who is so over‐weight as to be unable to undertake hikes of some duration probably would not do well in this program. Diabetes, epilepsy or other seizure disorders, hypoglycemia, extreme emotional volatility, or arthritis that might be exacerbated by extended exercise need to be evaluated case‐by‐case. The attached medical examination should be completed with these considerations in mind. Name: ________________________________________________ Date of Exam __/__/____ Birth date __/__/__ Age _______ Height _____ Weight_________ Allergies:________________________________________________ Integument ______________ Head ________________ Eyes: Glasses?____ Vision: R_______ L_______ Fundoscopic:_____ Ears____ Nose___ Throat _______ Neck: _____________________________________ Lymph: ___________________________________ Chest: ___________________________________ Heart: ______________________________________ Abdomen: _________________________________ Genitalia: ___________________________________ Lungs_____________________________________ Muscular‐skeletal: ____________________________ Nervous system ________________________________________________________________________ Blood Pressure ___________________________ Lower Extremities ______________________________ Hernia____________________________________ Back _______________________________________ PERSONAL AND MEDICAL HISTORY OF STUDENT Edema ________________________________Scoliosis?_______________________________________ (To be completed by Parent or Guardian) VACCINATIONS 1ST DOSE 2ND DOSE 3RD DOSE 4TH DOSE 5TH DOSE Polio D P T or TD Measles Rubella Mumps Has the applicant ever had any of the following diseases, illnesses or problems? If so, please Tuberculosis Test & Results date: Significant findings/recommendations/restrictions (please specify or indicate if none) General Appraisal ________Approval I find no defects that I find incompatible with the activities of the Semester Back Program. ________Disapproval‐ This applicant has physical defects which, in my opinion, clearly constitute unacceptable hazards to his/her health and safety in the activities of the Semester Back Program. Date: __________________________________ Print Physicianʹs name _____________________ 13 _______Initials PERSONAL AND MEDICAL HISTORY OF STUDENT To be completed by Parent or Guardian Student Name_________________________________ Age:_________DOB___________SS#________________ Last First M. Height_____________________Weight________________Waist Size__________________Shoe Size_________ Hair Color__________________Style of Cut____________Length_____________________Eye Color_________ Blood Type_________________Vision: Does this student wear glasses or contact lenses: Yes___No___ Family Physician___________________________________________Phone Number_______________________ Medical Insurance Information (to be used as necessary): Name of Group/Individual Health/Accident Insurance Company__________________________________ Policy Group Number________________________Member Number______________________________ Mailing Address:_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Is the student allergic to any of the following? If yes, describe reactions in detail: ___Penicillin _______________________________________________________________________________________ ___Sulfa Drugs______________________________________________________________________________________ ___Aspirin_________________________________________________________________________________________ ___Iodine or Shellfish________________________________________________________________________________ ___Other __________________________________________________________________________________________ Does the student have alldergies such as hives, hay fever, eczema, asthma, foods or others? ___If yes, describe:_________ __________________________________________________________________________________________________ __________ Red Measles __________ Arthritis __________ German Measles __________ Frequent colds/sore throat __________ Chicken pox __________ Ulcers __________ Mumps __________ Muscle weakness __________ Whooping Cough __________ Anemia __________ Epilepsy __________ Vision Problems __________ Scarlet Fever __________ Stomach __________ Rheumatic Fever __________ Sexually Transmitted Disease __________ Polio __________ Recent Cough __________ Convulsions/seizures __________ Numbness/tingling __________ Meningitis/Encephalitis __________ Night sweats __________ Pneumonia/bronchitis __________ Neurological __________ Heart disease __________ Dizziness/fainting __________ Menstrual __________ Bladder or kidney infection __________ Scoliosis __________ Currently pregnant __________ High Blood Pressure __________ Liver (jaundice) __________ Diabetes __________ Hepatitis __________ Hypoglycemia __________ Hearing __________ Dermatitis, Eczema __________ Headache __________ Venereal Disease __________ Constipation __________ Bone condition (knee, ankle, hip joint) __________ Heat exhaustion _______ Fever/Chills _______ Fatigue _______ Ear Infections _______ Cramps _______ Cancer/tumors _______ Circulation _______ Breathing _______ Asthma _______ Eating disorder _______ Surgeries _______ Accidents _______ Bed wetting _______ Nervous breakdown _______Chronic tranquilize use _______ Sleep _______ Vomiting _______ Weight Change _______Mouth sores/white patches _______ Other Explanation of the above: ___________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please list any other significant illnesses, diseases or disorders not listed above, including dates: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ______________________________________________________________________________________________ 14 _______Initials Exhibit E Solacium Alldredge LLC Family/Parent Questionaire Student’s Name____________________________________ Date __/__/____ Parent/ Child Relationship Describe your relationship with your son/daughter Mother (Name) ______________________/________________________________ First Last ______________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________________________________ Father (Name) ___________________________/___________________________ First Last ______________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ (If Applicable) Stepmother (Name)_______________________/___________________________ First Last ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ __________________________________________________________ Stepfather (Name)______________________/______________________________ First Last ______________________________________________________________________________________________ Sibling(s) Relationships Describe your son/daughterʹs relationship with his or her siblings Name Age Sex Type of relationship _______________________________________________________________________________________________ _______________________________________________________________________________________________ _________________________________________________________________ Other Family Members with whom your son/daughter has an important relationship (Grandparents, aunts, uncles, cousins) _______________________________________________________________________________________________ Adoption Was your son/daughter adopted? Yes _____ No ______ At what age? ____________________________ Were there any special circumstances? Explain: _____________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ Does adoption appear to be an issue? Explain: _______________________________________________________________________________________________ Moves Have there been any difficult moves to a new home or school(s)? Explain: _________________________________________________________ Separation/Divorce 15 _______Initials Are parents divorced? Yes________ No ________When?_________ How old was your son/daughter when the divorce was initiated________Completed _______ Date Date Has the divorce been an issue? Explain:________________________________________ With whom does your son/daughter reside? Mother Father Other(Specify please)__________Any past or current separation, divorce or custody battles? Explain: _______________________________________________________ School Current grade:_______________ Still Attending Suspended Expelled Withdrawn Name of school:______________________________________________Phone number______________ School counselor:________________________________________________________________________ Any recent suspensions/expulsions? Yes No When? __________Reason _____ Describe your son/daughter's general attitude, behavior, and academic performance in Pre-school/Kindergarten: _____________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Elementary:________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Middle/ Junior High School:___________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ High School:_______________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please describe your perceptions of your son/daughter's primary difficulties in school._____________________________ __________________________________________________________________________________________________ Emotional or Psychological Issues Describe any episodes of physical or sexual abuse, neglect or other traumatic events in your child's life. Has the student ever been hospitalized for psychiatric/psychological mental disorder? _____Yes ______No ___________________________________________________________________________________________________ Diagnosis:_________________________________________________________________________________________ ___________________________________________________________________________________________________ Brief description of circumstances, dates, etc.:_____________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________________________________________________ Describe any episodes of self-harm, cutting bizarre or unusual behaviors.________________________________________ __________________________________________________________________________________________________ ___________________________________________________________________________________________________ Physicians Name:_________________________________ Phone: ____________________ ___________________________________________________________________________________________________ Hospital: _________________________________________Phone: ____________________ Describe any depressive (Please features submit or unusual mood swings.____________________________________________________ appropriate psychological records for our examination) Has the student ever attempted or talked about suicide: Yes ________ No______ Attempt (s)_______ Approximate date(s) _______ _________ Method____________ Hospitalization? Talk?___________ Approximate Dates___________________ Describe the circumstances_____________________________________________________________________________ ___________________________________________________________________________________________________ Describe any episodes of physical or sexual abuse, neglect or other traumatic events in your child’s life._________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Describe any episodes of self‐harm, cutting, bizarre or unusual behaviors.___________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Describe any depressive features or unusual mood swings.________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 16 _______Initials Peer Relationships Describe your son/daughter's friends and social relationships: (good and bad influences, older or younger, new or old)________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Behavioral Problems Describe any problems your son/daughter has had in the following areas: Rebellion/Rage:____________________________________________________________________________________ _________________________________________________________________________________________________ Promiscuity: ______________________________________________________________________________________ _________________________________________________________________________________________________ Running Away (when, where and for how long?)_________________________________________________________ _________________________________________________________________________________________________ Stealing: _________________________________________________________________________________________ _________________________________________________________________________________________________ Lying: ___________________________________________________________________________________________ _________________________________________________________________________________________________ Violence/Aggression: (when, directed toward whom, circumstances)__________________________________________ _________________________________________________________________________________________________ Problems with the law (including any arrests and convictions/probation)_______________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Substance Involvement/ Drug History Types of substances used: Starting at what age? Under what circumstances? Socially or alone? How often? Are there other family members who have drug or alcohol problems?Explain____________________________________________ Strengths Describe your childʹs positive traits, strengths, hobbies, talent and interests:_______________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Church or religious activities, if any:_____________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Describe the most recent good time your child had with you and the family:______________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Skills & Capabilities Scouting________________________________ Athletics ____________________________________________________ Music _________________________________ Swimming (is your child a competent swimmer?) 17 _______Initials SOLACIUM ALLDREDGE LLC POWER OF ATTORNEY KNOW ALL PERSONS BY THESE PRESENTS, that I/we, ___________________________________________________ the legal parent(s) or guardian(s) (hereinafter the “Sponsor”) , residing at _____________________________________ make, constitute, and appoint Solacium Alldredge LLC (hereinafter “Alldredge Academy”), a Delaware Corporation, to be the true and lawful attorney‐in fact for ___________________________________________ (hereinafter the “Student”), for the purpose of providing custodial care and educational and clinical services. The Sponsor hereby delegates to Alldredge Academy all the Sponsor’s powers regarding care, custody and property of Student, as permitted by West Virginia law. Without limiting or qualifying, the general Power of Attorney delegated and assigned by the Sponsor in the paragraph above, the Sponsor specifically grants Alldredge Academy the following Power: 1. To provide or obtain any medical treatment and hospital care and to authorize a physician to perform any and all procedures that may appear to be medically necessary for the well‐being of the Student, including without limitation the implementation of life‐sustaining procedures, as determined in the sole discretion of Alldredge Academy; 2. To obtain medical records or information (including any of the Student’s individually identifiable health information and medical records regarding his/her past, present, or future medical or mental health condition, as well as any information or records governed by the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and the regulations promulgated thereunder) from any physician or other medical provider who has treated or consulted with the Student at any time, or from any other person who for whatever reason has access to or possession of such records, and to execute releases therefore; 3. To guide and discipline the Student as deemed necessary and reasonable by Alldredge Academy in its sole discretion (not to include corporal punishment); 4. To physically restrain the Student should he/she become a danger to himself/herself, or anyone else as deemed necessary by Alldredge Academy and it’s employees in their sole discretion; 5. To allow the Student to participate in various activities which may commonly risk physical injury including but not limited to traveling, snow skiing, mountain biking, snow tubing, swimming ,back packing, river rafting (Class 3 or lower), camping and various experiential therapies (R.O.P.E’s.); 6. To pursue all reasonable options to find and detain the Student upon his/her abandonment of the Alldredge Academy program, as determined in the sole discretion of Alldredge Academy. 7. It is our/my understanding that even though Alldredge Academy has been delegated custody over the student pursuant to the Power of Attorney while said student is enrolled in the program, we/I retain the right to revoke such delegation of legal custody at any time during the program. The Power of Attorney shall be effective until the earlier of (a) six (6) months from the date hereof or (b) the discharge of the Student from Alldredge Academy. The Signature of an authorized agent of Alldredge Academy, as the attorney‐in‐fact, indicating acceptance of the delegation of Power of Attorney and concomitant responsibility for the care of the Student follows. IN WITNESS WHEREOF, I/we have executed this Power of Attorney as of the _____ day of _____________, 20___. ____________________________________________________________________________________________________ Sponsor (Father/Guardian) ______________________________________________________________________________________________________ Sponsor (Mother/Guardian) ______________________________________________________________________________________________________ Authorized Representative of Alldredge Academy 18 _______Initials SOLACIUM ALLDREDGE LLC RELEASE OF STUDENT SCHOOL RECORDS Exhibit F SCHOOL STREET ADDRESS CITY STATE, ZIP CODE PHONE NUMBER _____________________________________________________________ (Student), born __________________ (M/D/Y) has enrolled in Alldredge Academy in the _______________ grade. I hereby request the release of his/her school records to be sent to Alldredge Academy. Please send the following to the address listed below. 1. Transcripts 2. Withdrawal Grades (include any incomplete classes, if applicable) 3. Health Records 4. Immunization Records 5. Accumulative folder 6. Test Date(s) 7. Special Education Records (include any counseling information) 8. Any additional information which would be of assistance in placing this student Please Fax Records to ALLDREDGE ACADEMY (304) 259‐5214 Send Hard Copy to P O BOX 310 DAVIS, WV. 26260 IN WITNESS WHEREOF, the undersigned legal guardian of the Student named above has executed this request as of the _____ day of _______________________, 20_____. ____________________________________________________________________________________________________ Sponsor (Father/Guardian) ______________________________________________________________________________________________________ Sponsor (Mother/Guardian) ______________________________________________________________________________________________________ Authorized Representative of Alldredge Academy Federal Law does not require a guardian’s signature for educational records to be sent to officials of another school or school system where the student seeks or intends to enroll. Exhibit G 19 _______Initials SOLACIUM ALLDREDGE LLC COMMITMENT TO THERAPY Solacium Alldredge LLC (“Alldredge Academy”) expects the parent(s) or guardian(s) (Sponsor) to be involved with the Student’s admission at Alldredge Academy. We expect parents (Sponsor) to take treatment seriously and make appropriate accommodations for therapy. If the treatment team concludes that family involvement is not occurring, Alldredge Academy reserves the right to arrange discharge of the Student. As the Sponsor, I commit to attend all family parent programs and make available reasonable time for weekly family communication. Signed this _______________________________________ day of ______________________________________, 20______________________________ ____________________________________________________________________________________________________ Sponsor (Father/Guardian) ______________________________________________________________________________________________________ Sponsor (Mother/Guardian) ______________________________________________________________________________________________________ Authorized Representative of Alldredge Academy Solacium Alldredge Insurance Information Some plans may cover the cost of your child’s clinical therapy while enrolled in Alldredge Academy. In addition, some Employee Assistance Programs (EAP) may have funding sources available. Check with your employer on this. Should your insurance company require a medical referral or pre‐authorization, contact your child’s home psychiatrist and/or medical physician to issue a referral or pre‐authorization for outpatient group, individual and family therapy. Alldredge Academy does not provide pre‐authorization for treatment. Please let the insurance companies know that you, the insurance holder, will be paying Alldredge Academy up front and that any reimbursement needs to paid directly to you, the insurance holder. Alldredge Academy respects your family’s right to confidentiality. Therefore, following your child’s stay, we will be providing you with a discharge packet. Included in the packet is the following information for you to submit to your insurance company: a breakdown of program costs; services rendered including CPT codes and diagnosis. If any further information is required by your insurance company, Alldredge Academy will make every effort to provide you, the insurance holder, with that information which you may then submit. 20 _______Initials SOLACIUM ALLDREDGE LLC FAMILY INFORMATION Student's Name: _________________________________________________________ M F Last First Middle DOB________________________________________ SS #________________________________________ Parents are Married Separated Divorced Re-married Deceased Father/Mother Where about unknown Father/Mother Who has legal custody of the child? ________________ Visitation _________________________________ ( In some cases it may be necessary to supply copies of court orders assigning rights) Financial Sponsor ( to whom bills should be sent) __________________ ________________________ __________ Name Signature Date Name Address and Phone number of person other than parents to be notified in case of emergency: Name __________________________________________ Relationship __________________________________ Address ________________________________________ Telephone____________________________________ _______________________________________________ Work Phone: _________________________________ Childs place of birth____________________________________________________________________________ Mother First Middle Last Maiden Home address City, State, Zip Code Contact numbers Home ____/_______________ Employed by Office ____/_______________ Fax ____/_______________ Cell ____/_______________ Occupation or title Education or degree E-mail: Father First Middle Last Home address City,State, Zip Code Contact numbers Home ____/_______________ Employed by Office ____/_______________ Occupation or title Fax ____/_______________ Education or degree Cell ____/_______________ E-mail: Step Parent First Middle Last Home address City, State, Zip Code Employed by Occupation or title Education or degree Contact numbers Home ____/_______________ Office ____/_______________ Fax ____/_____________ Cell ____/_______________ E-mail: 21 Initials SOLACIUM ALLDREDGE LLC LIST OF PERSONAL ITEMS Required personal items to bring the day of ADMISSION (SAR Phase) • Immunization Record~unless provided with application • School Transcript~unless provided with application • Three month supply of Prescription medications packaged in Doc‐u‐dose System ~ unless provided Directly by Pharmacy • 12 pair of plain white underwear~boxers or briefs for boys, hipsters for girls • 4 navy or grey short sleeve t‐shirts • 2 navy or grey long sleeve t‐shirts • 4 plain white sports bras (girls) • 10 pair white cotton crew socks • Elastic hair bands • One pair low top running shoes • One pair Teva like sandals (rubber soled with ankle straps) NO FLIP FLOPS • One bathing suit, boxer style for boys, modest one piece for girls (Yes, year round!) • 2 pair waist high/knee length khaki shorts (April — September only) Required personal items to bring to the SECOND PARENT PROGRAM (School Phase) • One pair of sweatpants—loose fitting, plain gray or dark blue • Three pair of waist high plain khakis‐Knee length shorts in summer, pants in winter • 4 navy or grey short sleeve t‐shirts • 4 pair plain white underwear ~ boxers or briefs for boys, hipsters for girls • 4 plain white sports bras (girls) Optional personal items to bring to the SECOND PARENT PROGRAM (School Phase) • One watch • Two disposable cameras • One pair of sunglasses • One acoustic musical instrument • Elastic hair bands • One seasonal coat (September — April). No logos, grey or dark blue. • Ski pants & equipment~Seasonal PLEASE DO NOT BRING ANYTHING THAT IS NOT ON THIS LIST. WE PROVIDE EVERYTHING ELSE THE STUDENT NEEDS. SLOGANS OR INSIGNIAS ON CLOTHING IS NOT PERMITTED. Alldredge Academy is not responsible for lost or misplaced personal property or clothing. 22 Initials Solacium Alldredge LLC Elopement Description Form Please understand that this form will be used in emergency situations. Please be specific. Student Name:_________________________________________________Date of Birth:____________________ Age:_______Race:_________Height:_____________Weight:______________Eye Color:__________ M or F Hair Color (please note natural or dyed color if applicable):__________________________________________ Distinguising Marks:____________________________________________________________________________ How long have your child lived at your current address?____________________________________________ Please list any previous home addresses:__________________________________________________________ ______________________________________________________________________________________________ Please list any friends or relatives that your child might contact (Name, Address, Phone Number, Relationship)_____ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Please list any schools that your child may have friends (Name of School, Contact Person, Phone Number)_________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ How many times has your child run away?________________________________________________________ Was your child alone?______ If not, who did they run away with?____________________________________ Where did your child run?_______________________________________________________________________ What was the reason or situation at that time?______________________________________________________ _______________________________________________________________________________________________ How long was your child gone?__________________________What was the reason for returning?_________ _______________________________________________________________________________________________ Student’s Social Security Number:__________________________Driver’s License Number:________________ Students Place of Birth:______________________ Blood Type:_________________ Students Cell Phone Number and who has physical possession of the phone?___________________________ _______________________________________________________________________________________________ Mother’s Maiden Name:_________________________________________________________________________ Who should the authorities and Alldredge Academy contact to inform of this situation? Name:_________________________________________________________________________________________ Relationship to Student:__________________________________________________________________________ Home Phone: ____________________ Work Phone:_____________________ Cell Phone:___________________ Should my/our son/daughter run away from supervision of Alldredge Academy staff during the term of the Alldrege Academy program, all appropriate law enforcement, security personnel, game wardens of any federal, state, county or municipal entity shall be directed to detain and retain custody of my/our son/daughter until travel is arranged for his/her immediate return to Alldredge Academy or my/our home. Alldredge Academy personnel and/or law enforcement shall be able to physically restrain, control, and detain my/our son/daughter for the purposes: 1. To prevent endangerment of him/her to themselves 2. To prevent him/her from hurting or endangering anyone in the program including other students/staff. 3. To prevent him/her from hurting or endangering law enforcement. ________________________________________________________________________________________________ Mother/Legal Guardian (please print) Signature Date ________________________________________________________________________________________________ Father/Legal Guardian (please print) Signature Date Alldredge Academy Staff Use: Description of Student’s clothing and equipment at time of Incident:_________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 23 Initials