Student's Name: Social Worker: Area Office: Phone #: UConn First Star Academy 2015 Application Checklist Please use this checklist to make sure the application is complete: 1. Student Application 2. DCF Medical Permission to Treat Form 3. Authorization of Visitors Form 4. Transportation Permission Form 5. Administration of Medication Form 6. Summer Program Health History Form 7. Attached student's most recent report card/transcript showing college bound courses 8. Individual Education Plan & Achievement testing (if applicable) 9. Copy of most recent CMT or CAPT scores (score at least proficient) 10. DCF Release of Information form (for UConn First Star program to communicate with the student's school) The summer program will be at UConn, Storrs Campus, from July 5 th - 31 st, 2015. *UConn First Star program is a college preparation program and is designed to expose the student to the subject content and prepare them for the upcoming year in school. It is not intended to replace or advanced the student in the district curriculum. Mail a complete application packet by April 1 st, 2015 to: Wendy Jackson, M.S. Post Secondary Education Consultant DCF Adolescent and Juvenile Justice Division 505 Hudson St. 9 th floor Hartford, CT 06106 *Incomplete applications will not be considered for admission. Thank you for applying to the UConn First Star Academy!
Section 1. Student Information: Please complete all questions fully. 1. Student s Name: _ Last First Middle 2. DCF Link Case #: DCF Participant Link #: 3. Placement Address: _ Number Street City State Zip Code 4. Phone: ( ) 5. Student E-mail: 5. Gender Male Female 6. of Birth: 7. Age: 8. Student s Medical Insurance #: 9. Race/Ethnicity (optional): African American Asian/American Native American Caucasian Hispanic Other 10. Legal Status: Committed Abuse/neglect/uncared for Termination of Parental Rights 11. Placement Type: foster care (relative, therapeutic etc.) Congregate Care 12. Current High School: 13. Current Grade: 14. School ID #: 15. Guidance Counselor s Name: 16. Phone: 17. Are you applying to or are you involved in any other academic programs or sports that might conflict with the summer? Yes No (If yes, please explain) 18. STUDENT STATEMENT: Explain why you would like to be in the First Star UConn Academy and what you hope to gain by participating in this program. Use additional paper if needed. 2
Section 2 a. Social Worker Information Student Name: 1. Placement/Foster Parent Contact Name: 2. Address: Number Street City/State Zip Code 3. Foster/Placement Home Phone Number: 4. Other Phone Number: 5. Social Worker s Name: 6. Phone Number: 7. Social Worker Email: 8. Cell Phone Number: 9. Social Work Supervisor: 10. Phone Number: 11. Program Manager s Name: 12. Phone Number: 13. Area Office Address: 14. Area Office Phone Number: Section 2 b. Student s Health History Information (this information will allow us to provide students with support services as needed. The medical information requested will not be used to discriminate potential applicants) 1. Medical Illness History: 2. Does the student have mental health history? Yes No 3. Any recent hospitalizations? Yes No If yes, please attach a discharge summary. 4. List all medications the student is taking, why he/she is taking them and is supervision to take meds needed: 5. What allergies does the student have? 6. Family Physician or Clinic: 7. Medical ID Number: 8. Mental Health Provider: 9. Phone Number: 10. Will this student need treatment while on campus? Please explain: 3
UConn First Star Academy Authorization to Visit and Take Off Campus Form The student s Social Worker should complete this form and provide the names of DCF authorized visitors and individuals approved to take the student off campus. Please attach additional copies of any relevant documents. You may use the back of this page to provide additional information that might be helpful. Student s Name: Social Worker Name: The following individuals have my permission to visit the student while on campus and can take the student off campus: Name: Relationship: Address: Phone Number(s) Name: Relationship: Address: Phone Number(s) Name: Relationship: Address: Phone Number(s) Are there any custody issues that the First Star staff should know about? Program Manager Signature Telephone # 4
UConn First Star Academy ADMINISTRATION OF MEDICINE CONSENT FORM Student's Name: DOB: I give permission for the above student to be administered cold medicine, Advil, Tylenol, or Aleve, as needed. DCF Program Manager Name DCF Program Manager Signature Telephone Number 5
UConn First Star Academy Transportation Permission and Consent for Extracurricular Activities The UConn First Star Academy sponsors many activities and events that require transportation provided by the program. We need a parent/guardian statement authorizing the student applicant to board authorized vehicles. PERMISSION STATEMENT: I hereby give permission to the University of Connecticut s First Star Academy to arrange transportation for my son/daughter, (student s name) to and from program s sponsored events, in vans, buses or other vehicles driven or arranged by the program personnel. I understand that this is a service provided to students who voluntarily wish to use the program s transportation. Therefore, the program will not be held liable in the event of an accident. Also, I understand that guardians are responsible for student transportation to the designated pick-up and drop-off locations. I hereby give permission for my son/daughter to participate in any trips/activities planned by the program staff during the six-week summer program. DCF Program Manager Name: Telephone Number DCF Program Manager Signature: 6
08/2011 (Rev.) STATE OF CONNECTICUT DCF 460 Department of Children and Families INFORMED CONSENT FOR NECESSARY OR EMERGENCY HEALTH CARE or REFERRAL Section I: TO BE COMPLETED BY DCF DESIGNEE AND FORWARDED TO LICENSED MEDICAL PROVIDER Name of Child: DOB: Medical Insurance Info: Legal Status: Placement Contact Name and Address: Area Office Social Worker: Phone/Fax: Supervisor Name: Phone/Fax: Qualified Health Care Professional: Address: Telephone/Beeper/Fax Section II: PROCEDURE OR TREATMENT REQUEST (TO BE COMPLETED BY QUALIFIED HEALTH CARE PROVIDER or RRG NURSE) Diagnosis or reason for referral: Name of procedure or treatment Description of procedure or treatment including risks/benefits: Description of any alternatives to proposed procedure or treatment: Type of anesthesia to be used: Pre/post-operative care needs: Comments: Qualified Health Care Provider Signature : THE UNDERSIGNED, HAVING THE AUTHORITY TO CONSENT ON BEHALF OF THE MINOR NAMED ABOVE, AND HAVING REVIEWED THE EXPLANATION GIVEN BY THE QUALIFIED HEALTH CARE PROVIDER, HEREBY CONSENTS TO SUCH PROCEDURE OR TREATMENT. Parent's Name and Signature (if child/youth under an OTC) : DCF Designee Name/Title: Signature: RRG Nurse initial (if needed) : DCF Area Office/Hotline/DCF Physician on Call: 7
UNIVERSITY OF CONNECTICUT - SUMMER PROGRAM- HEALTH HISTORY FORM PLEASE PRINT RETURN THIS FORM TO YOUR PROGRAM CONTACT PERSON LAST NAME FIRST NAME MIDDLE INITIAL HOME ADDRESS CITY STATE ZIP HOME PHONE PLACE OF BIRTH COUNTRY OF CITIZENSHIP DATE OF BIRTH SOCIAL SECURITY /ID # SEX MALE SUMMER PROGRAM NAME FEMALE PROGRAM CONTACT PERSON NAME HOME TELEPHONE PROGRAM CONTACT PHONE NUMBER NOTIFY IN CASE OF EMERGENCY RELATIONSHIP WORK TELEPHONE PERSONAL PHYSICIAN/HEALTHCARE PROVIDER NAME TELEPHONE # INSURANCE COMPANY NAME INSURANCE INFORMATION ADDRESS INSURANCE ID NUMBER GROUP NUMBER GUARANTOR FULL NAME (policy primary insured person, i.e. mom, dad, self, etc.) GUARANTOR ADDRESS (street, town, state & zip) GUARANTOR DATE OF BIRTH CONSENT FOR TREATMENT (IF UNDER 18 YEARS OF AGE SIGNATURE OF BOTH PARENT/GUARDIAN AND PATIENT IS REQUIRED) I grant permission for Health Services personnel at the University of Connecticut, Storrs, CT. to administer to me routine medical treatment for minor illnesses/injuries and to arrange for any emergency medical care if the circumstances at that time make it impossible for me to make that decision. Patient s Signature Parent s Signature (If patient is under 18) Parent/Guardian s Name (Please Print) Relationship Cell Phone # Chronic Medical Problem? Current medication? List PERSONAL MEDICAL HISTORY Previous surgery/hospitalization/injury? Explain Physical Disability Emotional problems requiring treatment? Explain ALLERGIES FOOD (LIST FOOD) LIFE THREATENING? YES NO DRUG (LIST DRUG) LIFE THREATENING? YES NO INSECT (LIST INSECT) LIFE THREATENING? YES NO DO YOU USE AN EPI PEN? LIFE THREATENING? YES NO OTHER (LIST) LIFE THREATENING? YES NO PLEASE COPY THIS HEALTH HISTORY FORM FOR YOUR RECORDS 8
Student Medication List Name of Student: : Medication and Dose Frequency and Time of Day/Night Reason for Medication Supervision by Nurse Required? 9