GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER

GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER Dear Parent, Verde Valley School is committed to providing your child with the best possible care. It is with this goal in mind that the school requires several forms to be completed and returned to VVS prior to a student s arrival on campus. These forms, and a checklist, are included in this document. We must receive these completed and signed forms by August 1, 2014. You may send these forms via email or fax, but if you do please mail or send originals to school with your child when he or she travels to VVS. Please be aware: Among the completed forms we must have on file prior to attendance are the VVS physical exam and the annual test for tuberculosis. If your child has had a positive TB skin test or if he or she has received the BCG vaccine a negative chest x-ray is required. In accordance with the Arizona State Department of Health, a complete immunization record is required and must include both the month and the year of the immunization series. This record must be completed and signed by a medical professional. If parents wish for their child to be exempt from immunization due to personal beliefs, medical or laboratory reasons, an Exemption from Immunization form must be completed as directed. A copy of the AZ School Immunization Requirements is included to present to health care providers with assistance in compliance with the required immunizations. The MEDICAL, DENTAL AND PSYCHIATRIC TREATMENT CONSTENT FORM and the PARENT AND STUDENT AGREEMENT FOR MEDICATIONS FORM are required. These must be completed, signed and dated by both the student and parent/guardian. The student will need a separate form for each medication he/she takes, so copies of this form should be made if necessary. Every student must have PROOF OF HEALTH INSURANCE by either a US based insurance company or a travel health insurance policy. Foreign insurance will not be accepted as it cannot be billed by doctors offices in the United States. Proof of health insurance coverage consists of a legible copy of the insurance card, including both front and back sides. Verde Valley School will purchase a policy (as part of the International Student Program Fee) for any international student who cannot show proof of acceptable coverage. As mandated by the Arizona State Department of Health, VVS will provide a hearing screening test free of charge to all ninth grade students and/or any student who is thought to be having difficulties with hearing. A parent/guardian or faculty member may request this test. If you have any questions or comments please don t hesitate to contact me by email at healthctr@vvsaz.org or by calling the school at 928-284-2272. Sincerely, Sally Slater, RN Director of Health Services 3511 Verde Valley School Rd Sedona, AZ 86351 Phone: 928.284.2272 Fax: 928.284.0432 WWW.VVSAZ.ORG

Verde Valley School Health Documents Checklist Please note that ALL health documents need to be completed and turned in BEFORE your child is permitted to arrive on VVS campus. We have provided the below checklist to help you ensure that you have included all of the necessary documents. As you complete the documents and please check them off the list and send them to Verde Valley School either by mail, fax or email. Mail: ATTN: Admission 3511 Verde Valley School Road, Sedona AZ 86351 Fax: 928-284-0432 Email: admission@vvsaz.org Health Record and Physical Examination Parent and Student Agreement for Medications Medical, Dental and Psychiatric Treatment Consent Form Proof of Health Insurance Immunizations Records (must be approved by Health Center prior to arriving on campus) Annual TB Skin test or Negative Chest x-ray Hearing & Vision screening (ages 16 and under) Your child MAY NOT be on campus until this checklist is COMPLETE, submitted to Verde Valley School AND you have been notified that all documents have been received and reviewed/approved. If you have any questions related to health documents, you may contact Sally Slater, Director of Health Services, directly at: Email: healthctr@vvsaz.org Phone: 928-284-2272 x24!!! 2!

MEDICAL, DENTAL AND PSYCHIATRIC TREATMENT CONSENT FORM I (we), parent(s) or legal guardian of, (Student s Name) who is a student at Verde Valley School, Sedona, AZ, hereby authorize the Health Center staff at the school to administer to my (our) child any medical/dental/psychiatric care, treatment or medication deemed advisable by a physician licensed by the State of Arizona or by any other qualified health professional under the general supervision of a license physician. I (we) further consent to the immediate transfer of my (our) child to any hospital or other medical facility or office in the event of an urgent or emergent medical, dental or psychiatric condition, and authorize a representative of the school to consent on my (our) behalf to any urgent or emergent medical, dental or psychiatric treatment to be rendered to my (our) child. I (we) further authorize any physician or health care provider who has rendered treatment to my (our) child to release to Verde Valley School any and all medical records relating to or necessary for my (our) child s treatment or diagnosis, in order to enable it to provide treatment for the physical and mental health of my (our) child. I (we) authorize Verde Valley School to release information to facilitate the medical, dental, psychiatric care of my (our) child or as is necessary to enable to provider of care to complete a claim for health insurance. I (we) understand and agree that I (we) are exclusively responsible for the payment of all medical services rendered to my (our) child other than services provided directly by the Health Center. The school assures the parent(s) or legal guardian that all reasonable efforts to contact them will be made before exercising this authorization. Parent/Guardian Name-Print Home Phone: Cell Phone: Work Phone: Home Address: Parent/Guardian Signature Date!! 3!

Health Record and Physical Examination Student s Name: Address: Date of Birth (M/D/Y): Age: Medical History Illnesses Please check the box only if your child has had the illness listed and write the date of the illness. Rubella: Rubeola: Whooping cough: Mumps: Chickenpox: Polio: ALLERGIES EXTREMELY IMPORTANT: Give history of ALL allergies, including drug or food allergies, and describe the reaction: Asthma Include treatment, name of medications and frequency of attacks, number of ER visits in the last year: Injuries and Fractures Provide dates and sites: Operations Provide dates and types: Female Provide menstrual history: Has applicant ever been evaluated or treated by a mental health care professional? If yes, give a brief description of condition: Name of mental health care professional: Address: Has applicant ever been evaluated or treated for substance abuse issues? If yes, give a brief description of treatment:

Physical Examination Pulse Resp B/P Ht Wt Findings State and explain any defects or abnormalities: Head Dental Exam: Most recent exam: Eyes Ears/Hearing Nose Mouth Orthodontia in progress? VISUAL EXAMINATION: R. EYE L. EYE Neck Glasses: Yes No Chest Contacts: Yes No Heart Lungs Abdomen Extremities Skin Reflexes-neuro REQUIRED FOR ADMISSION TUBERCULIN TEST Skin test: Date Given: Date Read: Result: (Any applicant with a positive reading must have a chest x-ray) Chest x-ray: Date: Result: REQUIRED FOR ADMISSION HEARING & VISION SCREENING IF AGE 16 AND UNDER Attach hearing and vision screening results to this form. Is applicant under any medical treatment? Yes No If yes, Please explain: Every student is required to participate in a sport. Should any limitations or restrictions be placed on applicants activities? Does applicant require any therapeutic measures or special care? If yes, explain: Does applicant take any medicine regularly or occasionally? Yes If yes, give medication, dosage and reason: No Name of Examining Doctor: Address: (Please Print) Signature of Examining Doctor: Date:!! 2!

REQUIRED FOR ADMISSION IMMUNIZATION RECORDS Please provide immunization records. Arizona Law requires that all immunizations must be verifiably documented by physician or clinic with dates. Please see attached immunization requirements and make sure your child has all required doses. Students WILL NOT be admitted if immunizations are not complete. 2013-2014 Arizona School Immunization Requirements, Kdg-12 th Grade 1. Students must have proof of all required immunizations, or valid exemption, in order to attend school. Arizona law allows exemptions for medical reasons, lab evidence of immunity and personal beliefs. Exemption forms are available from schools and at www.azdhs.gov/phs/immun/idr_forms. Homeless students are allowed a 5-day grace period. 2. The immunization record for each vaccine dose must include the date and name of doctor or clinic. 3. The statutes and rules governing school immunization requirements are: Arizona Revised Statutes 15-871 - 874; Arizona Administrative Code, R9-6-701 708. Please check requirements for each child s age and grade level in the chart below. Age Under age 7 7 10 years 11 years and older 11 years and older Grade Vaccine Kindergarten and above Kindergarten-5 th grades 6 th through 11 th grades only 12 th grade DTaP/DTP/DT Td Tdap Meningococcal Polio MMR Hepatitis B 4-5* doses At least 1 dose at 4 years of age or older is required. *A 6th dose is required if 5 doses have been given before 4 years of age. History of 4 DTaP or a total of 3 tetanus & diphtheria doses given after 12 months of age. Not required for 11+ year olds in these grades. Not required for 11+ year olds in these grades. 1 Tdap dose is required when 5 years have passed since their last DTaP, DTP, DT or Td. Students starting or finishing the first 3 tetanus & diphtheria doses of their lifetime must receive only 1 Tdap as part of the 3-dose series. 1 dose Students who have not already received Tdap are required to receive 1 Tdap dose when 10 years have passed since their last DTaP, DTP, DT, or Td. Students starting or finishing the first 3 tetanus & diphtheria doses of their lifetime must receive only 1 Tdap as part of the 3-dose series. 1 dose recommended, but not required for 12 th graders in the 2013-2014 school year. 3-4 doses 3 doses meet the requirement if the 3 rd dose was given at age 4 years or older. 4 doses meet the requirement even if all 4 doses were given in the first year of life. 2 doses A 3 rd dose will be required if dose #1 was given before more than 4 days before the child s 1 st birthday. 3 doses A 4 th dose will be required if the third dose was given before 24 weeks of age. 1 dose is required if the 1 st dose was given before 13 years of age. 2 doses are required if the 1 st dose was given at 13 years of age or later. Varicella Students attending school or preschool in Arizona prior to 9/1/2011 with parental recall of chicken pox disease are allowed to continue attendance with parental recall of disease. Students enrolling in an Arizona preschool or school for the first time after 9/1/11 are required to present proof of varicella immunization or a valid exemption for medical reasons, laboratory evidence of immunity or personal beliefs. Childcare and preschool immunization requirements are posted at http://www.azdhs.gov/phs/immun/back2school.htm Arizona Immunization Program Office 150 North 18 th Avenue, Suite 120 Phoenix, AZ 85007 (602) 364-3630 Toll-free (866) 222-2329 (1/18/13)!! 3!

PARENT AND STUDENT AGREEMENT FOR MEDICATIONS Please complete both sections of this form Student Name: Parent or Legal Guardian: PRESCRIPTION MEDICATION As the Parent or Legal Guardian for the above named Student, I understand that Verde Valley School must be informed of ALL prescription medication that the student is bringing to Verde Valley School. All pre-scription medication MUST be kept in the original container with the original prescription label. Medication will be kept locked in the Health Center. The student is required to visit the Health Center weekdays at an agreed-upon time to receive his/her medication. If medication is prescribed at nighttime, it will be dispensed by the Dorm Parent(s). On weekends, medication will be dispensed by the Administrator on Duty. Below please list prescription medications for the student. If student is taking more than one medication, print and complete additional forms. Name of medication and dosage: Instructions for Administration: Physician s name/phone number: Reason for medication: Occasionally, exceptions will be made regarding the administration of your child s medication. The pre-scribing doctor, parents, student, Director of Health Services and school administration must approve the exception. Please provide us with the information below by marking any boxes that apply to your child. My child is on medication that needs to be prescribed on an ongoing basis. This is how it is to be assessed and replenished: My child may see the medical provider arranged by Verde Valley School to determine prescription refills. OR My child s own physician will continue to prescribe this medication. It is my responsibility to obtain medications and send them to the Health Center when necessary. My child understands the administration and effects of the medication and is reliable about taking the medication him/her self. The medication will NEVER be shared with another person. Such behavior is a violation of a major school rule and could be grounds for dismissal. We understand that this privilege may be revoked if warranted.!! 5!

OVER THE COUNTER (NON-PRESCRIBED) MEDICATIONS Please provide us with the information below by marking the box (mark only one) that applies to your child. I withhold permission and DO NOT ALLOW Verde Valley School or its Health Center to administer ANY over-the-counter medications. By checking this box, I further acknowledge that VVS Health Center may, at its discretion, arrange for my child to see a medical provider should the need arise. My child has permission to receive over-the-counter medications at the discretion of the school nurse and as directed by the manufacturer My child is NOT PERMITTED to keep any over-the-counter medications on his or her person or in his or her dorm room. My child has permission to receive over-the-counter medications at his or her own discretion. My child may be allowed to keep medications and administer them to him/her self as needed. My child understands the administration and effects of the medication and is reliable about taking the medication him/her self. The medication will NEVER be shared with another person. Such behavior is a violation of a major School rule and could be grounds for dismissal. We understand that this privilege may be revoked if warranted. FOR ALL MEDICATIONS Verde Valley School cannot and does not assume any responsibility for determining the appropriateness of medications and dosages. Modifications or changes to prescription medication must be made in writing by the prescribing physician and sent to the Health Center. The student is responsible for obtaining the medication from the Health Center or School designee prior to vacations or other times when the student will be away from campus. It is the responsibility of the student to take all medications as prescribed and, if applicable, obtain his/her medication from the Health Center in a timely manner. A student who misses or is late for medication at the Health Center will be given a disciplinary violation. Any material non-compliance will be communicated to the parents. My signature below attests that I have read this entire agreement and that I understand it and its terms. Student Signature Date Parent/Legal Guardian Date!! 6!