medication administration modification authorization for ... · i/dd case management agency: ......

3223 North Oliver Avenue (Main Office) | Wichita, KS 67220 | (316) 267-KIDS | Fax: (316) 267-5444 www.RainbowsUnited.org

Bringing potential to life by elevating the uniqueness of children and their families.

Dear Parents & Guardians; Thank you for your interest in your child attending Camp Woodchuck 2018. It will be an exciting summer! We have many fun things planned for Camp and would like to provide you with some information to assist in Camp preparation. Please note, Camp spots will fill up quickly and are assigned on a first come first serve basis.

All forms in the application must be completed and received in office by April 27, 2018 in order to receive a June 4, 2018 start date. Partially completed packets will not be accepted by the office and enrollment in Camp is not finalized until the entire completed packet is received in our office. Upon completion of the packet or for assistance, please contact Alice Ridgeway 316.945.7117 ext. 107 or Teresa Shackelford at 316.945.7117 ext. 111 to schedule an appointment to review the packet. As a reminder a doctor’s signature on the Medication Administration and CACFP Meal Modification forms are required in order to provide appropriate care for your child. A witness signature is required on the Authorization for Emergency Medical Care form. A note about medication: A Rainbows’ Nurse will provide medications between 10am – 4:00pm. Medications needed before 10am or after 4:00pm should be given at home, unless other arrangements are approved ahead of time. All medications must be sent in original container and submitted to the nurse. Thank you for allowing your child to spend the summer with us. If you have any questions or concerns regarding this information, please contact Candace Staker at 316.945.7117 Ext. 105 or Tiffany Graf at 316.945.7117 Ext 140.

http://www.rainbowsunited.org/

Form No. 612 (2/9/2016)

FAMILY SUPPORT SERVICES Requests for Services Checklist

Child’s Name: Date Received:

Requests for Services Checklist

Request for Services Statement of Responsibility/Appointment of Agent Client Release Form Media Release Authorization for Release and/or Disclosure of Information Income Information and Sliding Fee Scale Payment Agreement Health History - 2 pages Seizure Care Plan (Required if history of seizures) Treatment Plan for Seizures (Required if history of seizures) Authorization for Emergency Medical Care (Requires witness signature) CACFP Enrollment & Income Eligibility

Information below requires a Dr.’s signature

CACFP Meal Modifications Request to Administer Medication

Provide current copies of the following information

Insurance Card Proof of Income (One month) Individual Education Plan (Schools) Behavior Plan (Schools, Specialists, Psychiatric Facilities)

Information below is obtained from Case Manager

Integrated Service Plans (ISP) Supportive Home Care Schedule (MR-10) Family Support Documentation Person Centered Support Plan

Information required for CAMP WOODCHUCK only Camp Woodchuck Request for Hours (Schedule) Grace Med Form Camp Enrollment Fee ($50) Credit Card Cash Check#

For office use only:

Scanned to F drive: (Printed name) (Signature) (Date)

Form No. 616 (5/15/2017)

FAMILY SUPPORT SERVICES REQUEST FOR SERVICES

Legal Name of Child: ______________________________________________ Today’s Date: _________________ Child ID # ___________ Date of Birth:_________________ Social Security Number:____________________________

Sex: M or F Ethnicity: Hispanic Y or N Race: White Black or African American Asian American Indian or Alaskan Native

Native Hawaiian or Pacific Islander Two or more races Some other race I would like my child to be enrolled for the following services as of (date) _________________ Please note there may be a waiting list for one or more of these services. _____ In-Home Support Services _____ Saturday Center _____ Sunday Center _____ AM Latchkey (Only available during Camp Woodchuck) _____ PM Latchkey (Available after school) _____ All Day Latchkey (Limited availability, preferred hours are _______am until ________ pm) _____ Camp Woodchuck (Information sent out in March)

Name of School: ____________________________________ Grade in School: _______________________________

Child has: (Indicate all that apply) ____ Behavior Plan (If yes, indicate where it is from) School? Y or N Parsons? Y or N Other organization? Y or N Name of organization? ___________________ ____ Takes medications to alter mood or behavior ____ Mental Health Diagnosis (examples: Aspergers, PTSD, Bi-Polar, etc) Diagnosis:___________________________ ____ Person Centered Support Plan (obtained from Case Manager: if no case manager, fill out Child Information form)

I/DD Case Management Agency: ______________________ Case Manager Name: ___________________________

Case Manager Phone Number: ________________________ Case Manager E-mail:___________________________

Parent/Guardian Information Child lives with: Both Parents Father Mother Grandparents Foster Parents Uncle/Aunt

Parent/Guardian Name: _____________________________ Parent/Guardian Name: _____________________________ Address: _________________________________________ Address: _________________________________________ City, State, Zip: ____________________________________ City, State, Zip: ____________________________________ Home Phone: _____________________________________ Home Phone: _____________________________________ Cell Phone: _______________________________________ Cell Phone: _______________________________________ Work Name: ______________________________________ Work Name: ______________________________________ Work Phone: ______________________________________ Work Phone: _____________________________________ E-mail: ___________________________________________ E-mail: __________________________________________ Relationship to Child: Father Mother Uncle Aunt Relationship to Child: Father Mother Uncle Aunt Foster Parent Grandparent Other: ________________ Foster Parent Grandparent Other: ________________ Education Level: 9-12th Graduated Some College Education Level: 9-12th Graduated Some College College Degree: AA BA/BS Grad School Masters PHD College Degree: AA BA/BS Grad School Masters PHD

How did you hear about RUI: Family Friend Physician School SRS RUI Staff Other:________________________

Print Parent/Guardian name Signed Parent/Guardian Name Date

Attach current photo of child.

Form No. 614 (Rev. 2/14/2018)

FAMILY SUPPORT SERVICES 2018 CAMP WOODCHUCK REQUEST FOR HOURS

Child’s Name: Date of Birth Today’s Date

Parent/Guardian Name:

Phone: Home Cell Work Schedule: Indicate times your child will attend Camp. Put an X through days your child will not attend Camp. Camp Hours: 8:00 AM - 4:00 PM Latchkey Hours: 7:30 AM – 8:00 PM & 4:00 PM – 5:45 PM Office Use Only

Week Monday Tuesday Wednesday Thursday Friday Weekly Hours

Weekly Total ($)

JUNE 28 29 30 31 1

1 4 5 6 7 8

2 11 12 13 14 15

3 18 19 20 21 22

4 25 26 27 28 29

JULY

5 2 3

4 Agency Closed

5 6

6 9 10 11 12 13

7 16 17 18 19 20

8 23 24 25 26 27

9 30 31

OFFICE USE ONLY Hours ($) Ratio: Totals:

Summer Activities: Indicate the name and dates of any additional summer school/programs your child will attend. ____ Name of Summer School/Program Location ___________________________________ Dates ________________ Transportation: Indicate the times your child will arrive/depart from Camp Woodchuck using a transportation system. ARRIVING DEPARTING ____ MTA (Metro Transit Authority) will transport my child. _________ ___________ ____ School Bus will transport my child. _________ ___________

Child’s shirt included with enrollment, to be provided the first week of June. Please indicate T-Shirt size below: Youth: _____ Small _____ Medium _____ Large Adult: _____ Small _____ Medium _____ Large _____ X Large _____ 2X Large

CAMP CLOSED

Form No. 611 (3/17/2017)

FAMILY SUPPORT SERVICES STATEMENT OF RESPONSIBILITY AND APPOINTMENT OF AGENT

STATEMENT OF RESPONSIBILITY On behalf of (child’s name) ________________________________________________, my dependent, I wish to receive Family Support Services. I have been fully informed of the scope of the Family Support Services program and agree to supply the staff with any and all information deemed necessary to safeguard the welfare of my dependent while being cared for by a Family Support Services staff. In the event emergency medical treatment is deemed necessary, and I am not readily available, I authorize such procedures as are necessary to ensure the health and well-being of my dependent. I understand that my dependent may become ill or injured during respite services and I agree that if this occurs through no negligence of the Family Support Services staff, I will not hold Rainbows United, Inc. and/or its employees liable for the illness or injury. I have fully disclosed to the staff of Family Support Services, Rainbows United, Inc. all pertinent facts about my dependent’s needs and problems; and acknowledge full responsibility if I fail to do so. ____________________________________ ____________________________________ ___________________ Print Parent/Guardian Name Parent/Guardian Signature Date APPOINTMENT OF AGENT I hereby appoint Rainbows United, Inc. as my agent and representative for the purpose of authorization and consent for hospital and/or medical care for (child’s name) ___________________________________________________________ This appointment is for illness or injury that may occur while (child’s name) _____________________________________ is in the care or custody of Rainbows United, Inc. This appointment is effective (today’s date) __________________ and will remain valid throughout my child’s enrollment at Rainbows United, Inc. unless I revoke it in writing. I understand that I remain legally liable for any and all bills for medical and/or hospital services, and I specifically release and hold harmless Rainbows United, Inc., agents, and employees from any liability thereof.

____________________________________ ____________________________________ ___________________ Print Parent/Guardian Name Parent/Guardian Signature Date

Form No. 588 (Rev. 2/22/2018)

FAMILY SUPPORT SERVICES CLIENT RELEASE FORM

Child’s Name: _______________________________________________ Today’s Date: ____________________ Child lives with: ____Father ____ Mother ____Other (specify)__________________________________________ Indicate the order in which Family Support Staff should contact the parents/guardians and provide a primary and secondary contact number used for contacting in an emergency situation. Primary Parent/Guardian Contact Name: ___________________________________________ Father or Mother

Primary phone number: ________________________

Secondary phone number: ______________________ Secondary Parent/Guardian Contact Name: _________________________________________ Father or Mother

Primary phone number: ________________________

Secondary phone number: ______________________ In addition to parents/guardians, I authorize Rainbows United Inc., Family Support Services staff to release my child to the persons listed below to pick up my child from Rainbows United, Inc. center or in-home care. List a minimum of two adults (required) and the preferred order of contact.

Name Address Primary Phone Number

Secondary Phone Number

Relationship to child

Rainbows United, Inc., Family Support Services staff is authorized to place my child on or off a Unified School District transportation vehicle (school bus/van) or MTA bus, or other transportation service vehicles if applicable.

Name of Transportation Services Contact Person

Approximate Time of Day (RUI arrival or departure)

Location (arrival or departure from)

Company Phone Number

I understand that I am responsible for the following:

1. Notifying Rainbows United, Inc. Family Support Services in writing if any person on this list no longer has my permission to pick up my child.

2. Advising all persons listed above about the need to provide picture identification and that the identification must be presented in order to pick up my child.

Printed Parent/Guardian Name Parent/Guardian Signature Date

Media Release ASSIGNMENT OF RIGHTS AND RELEASE OF INFORMATION

FOR MEDIA, MARKETING, DEVELOPMENT AND COMMUNICATIONS

Purpose for Release of Information: Media, internal and external awareness, including, but not limited to, websites, social media, artwork, contests, printed material, etc.

I, ______________________________________________________________ the legal guardian of (CHILD’S NAME) ________________________________________________ OR I, ___________________________________ an adult eighteen years of age or older do hereby assign RAINBOWS UNITED, INC. (and affiliates) and all staff members and forever release the right to PHOTOS, ELECTRONIC FILES, ARTWORK, OTHER VISUAL IMAGES, STORIES, QUOTES or PERSONAL INFORMATION taken on or created by this individual. I understand that the intended use of these visual images, written stories and/or artwork is for media relations, marketing, communication or other means of public relations, advocacy, fund raising and development projects to benefit RAINBOWS UNITED. I understand these images and artwork will become the property of Rainbows United and we will have no claim to future compensation, benefits, rights or royalties. I release RAINBOWS UNITED from any claim, suit or action based on the use or publication of visual images. I do give my permission for media release

I do not give my permission for media release Executed THIS _______ DAY OF ______________, 20_____. __________________________________________ Signature of Legal Guardian or Participant Participant’s Contact Information:

Address:

Phone: ( )

Email address:

Rainbows United, Inc. 3223 North Oliver Avenue, (main office) Wichita, Kansas 67220 (316) 267-5437

Form No. 594 (Rev. 1/22/2014)

A photocopy of this Authorization shall be effective and valid as the original. Form No. 589 (2/22/18)

AUTHORIZATION FOR RELEASE AND/OR DISCLOSURE OF HEALTH INFORMATION

Child Name: Date of Birth:

Address: _____________________________________________________________________________ AUTHORIZATION I hereby authorize Rainbows United to: ____ Disclose health information to ___ Request health information from To the following person or entity: Name: _______________________________________________________________________________

Address: City: State: Zip Code: Phone: FAX: For treatment date(s): For the following purpose(s): _______ Evaluation Case coordination Treatment Follow-up care

Other (specify) INFORMATION TO BE DISCLOSED (MARK ALL THAT APPLY): ___COMPLETE RECORD Summary report of services received Consultation and/or verbal communication between the above named parties Other (specify) This authorization shall remain in effect until (date) or ____________ (occurrence of specified event) at which time this authorization to disclose identified health information expires, but no later than one year from the date listed below. If this item is left blank, the authorization shall remain effective for 90 days after the date listed below. I understand that treatment is not conditioned upon the execution of this authorization. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by those regulations. I understand that reasonable fees may be charged for preparing and sending copies of records. I understand that I may revoke this authorization at any time (except to the extent that action has been taken in reliance upon it) by providing written notification to Rainbows United Mental Health Department. _____________ _____________________________________________________ Date Signature of Individual/Individual’s Representative _________________________________________ Printed Name of Representative and Relationship Representative Address and Telephone Number

Form No. 615 (2/23/2018)

FAMILY SUPPORT SERVICES INCOME INFORMATION AND SLIDING FEE SCALE

Child’s Name: __________________________________ Parent’s Name: _______________________________ Total number of members in household: _________________ Number of Adults _______ Number of Children ______ My child has medical insurance (circle): Yes or No Medical Card/Insurance Number: __________________ My child receives SSI (circle): Yes or No

Check mark your households total gross income. Household gross income includes income for all people currently residing in the home where child lives.

Gross Income Sliding Fee Rate Gross Income Sliding Fee Rate _____ 0-$10,000 $5.00 _____ $70,001-$80,000 $7.00 _____ $10,001-$20,000 $5.00 _____ $80,001-$90,000 $7.50 _____ $20,001-$30,000 $5.00 _____ $90,001-$100,000 $8.00 _____ $30,001-$40,000 $5.00 _____ $100,001-$125,000 $9.50 _____ $40,001-$50,000 $5.50 _____ $125,001-$150,000 $10.25 _____ $50,001-$60,000 $6.00 _____ $150,000 and above $12.63 _____ $60,001-$70,000 $6.50 _____ Trust Fund $12.63

The sliding fee rate schedule is based on the total household income of the person receiving support services. The total household income includes all people living in household who receive income. Persons receiving family support may access the sliding fee scale once this funding source has been utilized at the $12.63 per hour rate. If you would like access to the sliding fee scale, please complete the following chart.

Household Member Name (First & Last)

Relationship to Parent/Guardian

Date of Birth

Gross Wage (pre- tax)

SRS TANF

Benefits

SSI Or

SSDI

Adoption Subsidy or

Child Support

Other Amount (specify source)

Total Monthly Income

Total Monthly Income

Annual Income (Monthly Income x 12) =

Additional Information • All care that is not covered by Family Support Funding or HCBS/IDD funding requires full payment before

receiving care. • Families using private or Family Support funds for Camp will be charged for all days scheduled. Credit will not be

given for days client does not attend. • Sliding Fee Rate will not be adjusted according to the level of care a child needs. • Rainbows’ does not provide care for typical sibling in either a family’s home or Rainbows’ Center. • I will notify Rainbows when there is a change of income or amount of members in household.

I hereby certify that all of the above information is true and correct. I understand that this information is being given in connection with the receipt of Federal Funds; that Rainbows United officials may, for cause, verify information; and that deliberate misrepresentation may subject me to prosecution under applicable State and Federal criminal statutes.

Printed Name of Parent/Guardian Signature of Parent/Guardian Date

Form 539 (Rev. 2/23/2018)

FAMILY SUPPORT SERVICES PAYMENT AGREEMENT

This Agreement is entered between Rainbows United, Inc. and (parent/guardian’s name) ___________________________________,

the parent(s) and/or legal guardians(s) of (child’s name)________________________________________. As the parent/legal guardian of the above named person, I have asked Rainbows United, Inc. to provide services for him/her. I agree to pay Rainbows United, Inc. for services rendered by a person acting on behalf of this Agency. I understand that the rate for care is based on the income of my household which may include but is not limited to wages, child support, SSI payments, subsidies (such as Adoption), and any direct financial assistance. Furthermore, I will provide Rainbows with proof of my household income before accessing the sliding fee scale. Please submit proof of your total household income, for one month, with your application, i.e., pay check stubs , court order for child support, SSI letter showing monthly amount, food stamp notice showing monthly amount. (Sliding fee scale does not apply to agencies funding a service i.e. foster care agencies.) Please initial the option that applies:

_____ My child receives HCBS-I/DD or HCBS/Autism Waiver services, I understand that Medicaid will pay Rainbows for the service provided according to the approved hours of the Plan of Care. I understand that Medicaid requires the Agency to bill private insurance before billing Medicaid. I will ensure that Rainbows has a copy of the Plan of Care and the Prior Authorization. After the approved hours are used, I can access the sliding fee scale for additional hours. My rate for additional hours, according to the sliding fee scale will be $_____________ per hour.

_____ My child has supplemental funding from: (agency) ____________________________ for _________________________

(other) ____________________________ for _________________________ I understand that this funding will be billed at the rate of $12.63 per hour until the funding is no longer available. I will then be able to access the sliding fee scale. My rate according to the sliding fee scale will be $_____________ per hour.

_____ I choose to private pay as my child does not receive any I/DD funding to supplement the cost of services. My rate according to the sliding fee scale will be $_____________ per hour.

Payments are due by the end of business on Monday of each week prior to your service week. A $50 returned fee will be charged for any returned bank drafts/checks, in addition to any applicable late fees. Accounts with more than one returned check will be required to pay by money order or credit card. I understand Rainbows United, Inc. may terminate services for the following reasons for non-compliance of statements:

_____ I do not complete a new application upon request; or _____ I do not schedule care through the Family Support Services office; or _____ I provide false and/or inadequate information regarding the above named person’s care; or _____ I refuse to comply with a request for verification of my household income; or _____ I do not pay for the services received.

I understand Rainbows United, Inc. will not continue services beyond the services listed on the Plan of Care without this signed Payment Agreement on file. The same will apply if payments are not up to date. It is the responsibility of the family and/or guardian to ensure that this signed Payment Agreement has been returned and that payments are made on time. Please initial one of the following options: _____ My dated signature on this form signifies my acceptance of this agreement until I revoke it in writing. I understand that all hours of services through Rainbows United must be scheduled with the Family Support Services Scheduler. I have completed and enclosed the Private Pay Income Information and Sliding Fee Scale form and verification of my household income with this Agreement.

Printed Parent/Guardian Name Signature of Parent/Guardian Date

_____ My dated signature on this form signifies my acceptance of this agreement until I revoke it in writing. I understand that all hours of services through Rainbows United must be scheduled with the Family Support Services Scheduler. I choose not to complete the Private Pay Income Information and Sliding Fee Scale form and/or enclose proof of total household income. Therefore, I may not access the Sliding Fee Scale, and my rate will be $12.63 per hour.

Printed Parent/Guardian Name Signature of Parent/Guardian Date

CCL. 358 Kansas Department of Health and Environment Rev. 3/2017 Bureau of Family Health Child Care Licensing Program

1000 SW Jackson, Suite 200 Topeka, KS 66612-1274

Phone: (785) 296-1270 Fax (785) 559-4244 Website: www.kdheks.gov/kidsnet

HEALTH HISTORY FOR CHILDREN AND YOUTH ATTENDING SCHOOL AGE PROGRAMS As required by K.A.R. 28-4-590(d) (1), each operator shall obtain a health history for each child or youth, on a form supplied by the department or approved by the secretary. Each health history is to be maintained in the child’s or youth’s file on the premises. As required by K.A.R. 28-4-590(d)(2), each operator shall require that each child or youth attending the program has current immunizations as specified in K.A.R. 28-1-20 or has an exemption for religious or medical reasons. Complete one form for each child or youth attending the School Age Program.

First and Last Name of the Child or Youth

Gender (M or F)

Date of Birth (MM/DD/YYYY)

First day at this program: (MM/DD/YYYY)

First and Last Name of the Child’s or Youth’s Mother or Guardian

Mother/Guardian’s Home Street Address

City Zip Code Home Phone # ( )

Mother/Guardian’s Work Place Name & Street Address

City Zip Code Work Phone # ( )

First and Last Name of the Child’s or Youth’s Father or Guardian

Father/Guardian’s Home Street Address City Zip Code Home Phone #

( )

Father/Guardian’s Work Place Name & Street Address

City Zip Code Work Phone # ( )

Names and ages of other children in the Child or Youth’s Family (Attach additional page if needed.)

Person(s) authorized to pick up the Child or Youth in case of emergency. Include first and last name and Street Address. Attach additional page if needed. 1.

City Zip Code Phone Number (during program hours):

2.

3.

First and Last Name of Physician & Street Address City Zip Code Phone Number

( )

Name of Hospital Preference in case of emergency.

Yes No N/A Complete the following information about medications for this child or youth.

Will this child or youth need to take any nonprescription or prescription medication during their time at the program?

If yes above, is there signed permission on file?

Circle any of the following conditions or difficulties that affect this child or youth.

Allergies Frequent sore throats/ colds Ear Infections or Aches Heart or Lung Conditions

Skin Problems Asthma Headaches Diabetes

Vision Speech/Communication Hearing Emotion/Behavior

Other: Please describe.

If you circled any of the above conditions, please provide additional information that will help the staff members meet the child’s or youth’s needs while attending the program. (Attach additional page, if needed.)

Provide additional information about your child or youth that might affect him/her while at the School Age Program including any special needs, restrictions to activities, major changes at home or special instructions. (Attach additional page, if needed.

Complete the following information about this child’s or youth’s immunization status.

Yes No

Did this child or youth attend a public or accredited non-public school in Kansas, Missouri or Oklahoma the previous year?

If yes, are this child’s or youth’s immunizations current?

If yes to both of these questions, you do NOT need to complete the immunization history below. If no to either of the above questions, you must complete the immunization history below for this child or youth or attach a copy of the child’s or youth’s immunization history.

Please give dates in the space below for ALL immunization series completed by this child or youth. Record MM/DD/YYYY.

1 2 3 4 5

DPT, DT*, TD (*DT only if child is allergic to DTP) / / / / / / / / / /

POLIO / / / / / / / /

MMR / / / / Single

Dose

Only

RUBEOLA (MEASLES) / / / /

MUMPS / / / /

RUBELLA (GERMAN MEASLES) / / / /

HIB (Hemophilus Influ. B) *RECOMMENDED / / / / / / / /

HBV (Hepatitis B Vaccine) *RECOMMENDED / / / / / /

VAR (Varicella-Chicken Pox) *RECOMMENDED / /

Print the First and Last Name of the Person Completing this Health History form

Relationship to the Child/Youth

Date Completed

If the Health History form was completed by a person other than a Parent/Guardian, who provided you with this information?

What is that person’s relationship to the child/youth?

I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this form is true and correct. Signature of person completing this form Date Signed

Form No. 598 (2/22/2018)

SEIZURE CARE PLAN Child’s Name: Date of Birth: Physician: Physician Phone Number:

Do we have your permission to call the above physician should questions arise regarding your child’s health here at school? Yes No

How long has your child been diagnosed with a seizure disorder?

I would describe my child’s seizures as: Simple Partial – Remains conscious, twitching or numb sensation, usually lasting less than 30 seconds.

Complex Partial – Altered consciousness, transient staring, feelings of unreality and detachment. May have hallucinations, unexplained feelings of fear, disrupted memory, teeth grinding, lip smacking, chewing, swallowing, scratching or pulling at buttons. Usually lasts no longer than 1-2 minutes.

Tonic-Clonic – Abrupt arrest of activity, loss of consciousness, symmetrical and rhythmical alterations of contraction and relaxation of major muscle groups. Ends suddenly in less than 5 minutes.

Atonic – Abrupt loss of postural tone, loss of consciousness, confusion, lethargy and sleep. (May just fall asleep suddenly; when laughing, the child may fall down.)

Myoclonic – Brief random contractions of a muscle group, may occur on one side of the body, no loss of consciousness.

Absence – Very brief periods of altered awareness, eyelids may flutter or twitch, blank facial expression, lasts 5-10 seconds but can occur repeatedly.

Tonic – Lack of movement, stiffening of the entire body musculature, arms flex, legs, neck and head extend. Peculiar, piercing cry, cyanosis (bluish coloring to skin), may temporarily stop breathing, increased salivation.

Akinetic – No movement, but muscle tone is maintained. Like “freezing into position,” may lose consciousness.

My child does does not have an aura before his/her seizures. (An aura is a sensation just before a seizure happens – may be a sound, sight, smell, feeling – they usually can tell if a seizure is about to happen.) If so, what is the aura?

Parent/Guardian Signature Date

Form No. 598 (2/22/2018)

TREATMENT PLAN FOR SEIZURES Child’s Name: Date of Birth:

Treatment: Assist the student to the floor, if needed. DO NOT put anything between teeth or in mouth. DO NOT restrain. Clear area to protect student from injury. Start a written record of the seizure behavior and treatment including length of seizure

activity. Notify parents. CALL 911 IF: seizure activity is different from “usual seizure activity” documented below,

child’s breathing is affected, it lasts longer than five (5) minutes or child fails to regain consciousness after seizure activity has stopped.

Child’s usual seizure activity includes:

Should the seizure activity last longer than , 911 should be called. (Please note: 911 will be called by school staff for any seizure activity lasting five (5) minutes.)

After seizure: Permit student to rest. Continue to document the episode. Monitor for second episode. Monitor for confusion or lack of consciousness.

If I cannot be reached by phone and my child does not respond to the above medication and treatment, I give my permission for school staff to call the physician listed on front side of care plan and follow his/her instructions. If the physician orders hospitalization or my child is exhibiting symptoms of a medical emergency, my child will be transported to the nearest hospital. I also understand that school staff can and will be informed of my child’s health concerns in order to provide safe, appropriate care.

Parent/Guardian Signature Date

CCL 010 Kansas Department of Health and Environment Rev. 3/2017 Bureau of Family Health 1000 SW Jackson, Suite 200 Topeka, KS 66612-1274 Child Care Program: (785) 296 -1270 Fax: (785) 559-4244 Website: www.kdheks.gov/kidsnet

AUTHORIZATION FOR EMERGENCY MEDICAL CARE Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4-582(e)(2).

Name of facility exactly as stated on the license.

License #

I hereby authorize _________________________________________________________ (Name of individual/staff member) and/or ____________________________________________________ (Name of individual/staff member) who is (are) representative(s) of the above named facility to give consent for any and all necessary emergency medical care for my child or youth _____________________ ___________________________________________ (First and Last Name of Child or Youth) while said child or youth is in said facility’s custody between the dates of ___________________________ and ____________________________. MM/DD/YYYY MM/DD/YYYY

Signature of Parent or Guardian Date Signed

Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic. Date Signed

Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.

State of Kansas County of ________________________

Signed or attested before me on ____________________ by______________________________________________. MM/DD/YYYY Name of Person (Seal, if any.) _______________________________________________ Signature of notarial officer

______________________________________________ Title (and Rank) My appointment expires: __________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency: Is child covered by health insurance? Yes No If yes, complete the following: Health Insurance Policy Name _________________________________________ Policy Number ______________________ Medical Assistance Program ____________________________________________ Card Number________________________ Military Medical Care I.D. Number ___________________________________________________________________________ If known, date of last Tetanus inoculation: __________________________________

THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST ALSO BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THE FACILITY.

Dear Parent or Guardian:

Our center has been approved for participation in the Child and Adult Care Food Program (CACFP). The CACFP reimburses the center for the partial cost of meals. Participation in the CACFP enables us to keep our fees lower as well as serve nutritious meals to children in our program.

The parent/guardian must complete Parts 1 and 4 and one of the following options: Part 2, Part 3A or Part 3B, to determine the amount of CACFP funds the center will be eligible to receive. This form will be placed in our files and treated as confidential information. Note: no white out or erasure should be used. If there is an error cross through, correct, and initial. Part 1 FOR CHILD ENROLLMENT:

CHILD’S NAME: List the first and last name of all children enrolled at this center. DATE OF BIRTH: List each child’s date of birth. TIMES OF CARE, DAYS OF CARE and MEALS SERVED: List the regular times of care for each child by listing their arrival time and leave time,

check each day the child will be in care and check each meal type received while in care. ETHNICITY/RACE: Using the codes provided, enter the codes for ethnicity and race. FOSTER CHILD: If the child is a foster child (the legal responsibility of a foster care agency or the court), please check the box.

Part 2 FOR A HOUSEHOLD RECEIVING BENEFITS FROM THE FOOD ASSISTANCE PROGRAM (FAP), TEMPORARY ASSISTANCE FOR FAMILIES (TAF), OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR):

Complete Parts 1, 2 and 4 on the reverse side. Provide the name and case number for the program from which benefits are received.

Part 3A FOR A HOUSEHOLD EXCEEDING THE INCOME GUIDELINES LISTED ON THE CHART BELOW: Complete Parts 1, 3A and 4 on the reverse side.

TO CALCULATE ANNUAL INCOME Weekly Income X 52 Every 2 Weeks Income X 26 Twice a Month Income X 24 Monthly Income X 12

Part 3B FOR ALL OTHER HOUSEHOLDS:

Complete Parts 1, 3B and 4 on the reverse side using the additional information below. HOUSEHOLD NAMES: Write the names of everyone in your household not listed in Part 1. Include yourself and all other children, your spouse,

grandparents, other relatives and unrelated people in your household. Use a separate sheet of paper if you do not have enough space. GROSS INCOME BEFORE DEDUCTIONS: Write the amount of income each person gets on the same line as their name. Use the appropriate

column(s): Earnings from Work, Welfare/Child Support/Alimony, Pensions/Retirement/Social Security or Other Income (see list below). Next to the amount of income write how often the income was received. Income is all money before taxes or anything else is taken out. If a person does not have income, check the box for zero income.

OTHER INCOME: strike benefits, unemployment compensation, worker’s compensation, disability benefits, interest/dividends, cash withdrawn from savings, income from estates/trust/investments, royalties/annuities/rental income, and regular contributions from persons not living in the household. FOSTER CHILDREN: List any personal income received by the foster child under Part 3B. Personal income is (a) money given for the child’s personal use, such as clothing, school fees and allowances and (b) all other money the child gets, such as money from his/her family. MILITARY HOUSING BENEFITS: Report off-base housing allowance as income. If the housing is part of the Military Housing Privatization Initiative, do not include as income. SELF-EMPLOYMENT: Report income derived from the business venture less operating costs for net income. The loss from the business cannot be deducted from a positive income earned in other employment. The least possible income is zero.

SOCIAL SECURITY NUMBER: Write the last four (4) digits of the social security number of the adult household member who signs the form. If the adult household member does not have a social security number, check the box. Use of this information is for CACFP use only and is required.

Part 4 SIGNATURE AND CONTACT INFORMATION:

Sign and date the application. The form must be signed by the parent or guardian. Complete the contact information – name, address, telephone number, and employer information.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) Mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

(2) Fax: (202) 690-7442; or (3) Email: [email protected]. This institution is an equal opportunity provider.

Household Size: 1 2 3 4 5 6 7 Each Add’l Family Member

Annual Income: $22,311 $30,044 $37,777 $45,510 $53,243 $60,976 $68,709 + $7,733

ENROLLMENT & INCOME ELIGIBILITY FORM FOR CHILD CARE CENTERS JULY 1, 2017 THROUGH JUNE 30, 2018

Part 1. CHILD ENROLLMENT: Complete the information below for all children in care. If the child is a foster child (legal responsibility of a foster care agency or the court), please check the box.

Last Name, First Name

Date of Birth

Times of Care Regular Days of Care Meals Served During Care

Ethnicity/ Race* Foster

Child Arrival Time

Leave Time M T W T F S S B A

M L P M D E

V Ethnicity Race

*Ethnicity (select one): H=Hispanic or Latino or N=Not Hispanic or Latino *Race (select one or more): W=White, B=Black or African American, I=American Indian or Alaskan Native, A=Asian, or P=Native Hawaiian or other Pacific Islander

Part 2. HOUSEHOLDS RECEIVING BENEFITS FROM THE FOOD ASSISTANCE PROGRAM (FAP), TEMPORARY ASSISTANCE FOR FAMILIES (TAF), OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR): Complete Parts 1, 2 and 4.

Program Name: ___________________________________________________________ Case No. _____________________________

Part 3A. HOUSEHOLDS EXCEEDING THE INCOME GUIDELINES: Complete Parts 1, 3A and 4.

If your family income exceeds the income guidelines (listed on reverse side), check this box

Part 3B. ALL OTHER HOUSEHOLDS – If you do not have a FAP, TAF or FDPIR case number: Complete Parts 1, 3B and 4. GROSS INCOME BEFORE ANY DEDUCTIONS (Net for Self Employed)

W=Weekly E2=Every 2 weeks 2M=Twice monthly M=Monthly Y=Yearly

List the Names of All Household Members not listed in Part 1

Earnings from Work Welfare, Child Support, Alimony

Pensions, Retirement, Social Security All Other Income

Check

If ZERO income

How much? How often? How much? How often? How much? How often? How much? How often?

(Example) Jane Smith $200 W $150 2M $100 M 1

2

3

4

5

6

Social Security Number of Household Member who signs form: Last four digits of Social Security Number: XXX- XX -____________ If you do not have a Social Security Number, check this box

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Food Assistance Program (FAP), Temporary Assistants for Families (TAF) or Food Distribution Program on Indian Reservation (FDPIR) case number for your child or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the CACFP.

Part 4. SIGNATURE AND CONTACT INFORMATION:

I certify that all information on this form is true and that all income is reported. I understand that the facility will receive Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose their meal benefits, and I may be prosecuted. _____________________________________ Signature of Parent or Guardian Date

________________________________________________ Print Name ________________________________________________ Address ________________________________________________ City State Zip Code ________________________________________________ Daytime Telephone ________________________________________________ Employer(s)

FOR CENTER USE ONLY _____ FAP/TAF/FDPIR HOUSEHOLD _____ Homeless Documentation from school, emergency shelter, or agency _____ ANNUAL INCOME: _________________ HOUSEHOLD SIZE: _________ __________________________________________________________________ Sponsor’s Determining Signature Date __________________________________________________________________ Sponsor’s Confirming Signature Date

HOUSEHOLD CATEGORY: Free Reduced Price Paid

Foster Child – Free Category List name of foster child(ren):

Kids’ Cove

12/2015 Child Nutrition & Wellness, Kansas State Department of Education Form 4-B

CACFP Meal Modification Form Important! Select the applicable meal modification category from the three listed below. Then carefully read and follow the

procedures for that category. The center/home will return an incomplete Meal Modification Form to the parent/guardian. If you have questions about this form, the center/home will assist you.

1. Modification due to a disability:

A center/home is required to make meal modifications prescribed by a medical authority to accommodate a participant’s disability. See the definition of disability on the back of this form.

Part B of this form must be completed by a “medical authority” that is authorized by Kansas state law to write medical prescriptions: licensed physician (MD or DO) OR a physician’s assistant (PA) or an advanced registered nurse practitioner (ARNP) authorized by their responsible licensed physician.

Parts A and C of this form must also be completed before the center/home can make meal modifications.

The meal modifications will continue until the medical authority requests that the modifications be changed or stopped by completing Form 4-G with the change. The form is available from the center/home.

It is strongly recommended that the medical authority annually update the prescribed diet order.

2. Modification due to a food allergy/intolerance, or other medical condition that does not rise to the level of a disability:

A center/home has the option to make meal modifications prescribed by a medical authority due to a food

allergy/intolerance or other medical condition that does not rise to the level of a disability.

Part B of this form must be completed by a “medical authority” that is authorized by Kansas state law to write medical prescriptions: licensed physician (MD or DO) OR a physician’s assistant (PA) or an advanced registered nurse practitioner (ARNP) authorized by their responsible licensed physician.

Parts A and C of this form must also be completed before the center/home can make meal modifications.

If a center/home chooses to make the meal modifications, they will continue until a medical authority requests that the modifications be changed or stopped by completing Form 4-G. The form is available from the center/home.

It is strongly recommended that a medical authority annually update the prescribed diet order.

3. Substitution for fluid cow’s milk due to lactose intolerance, allergy, religious, ethical or cultural reasons:

A center/home has the option to make a substitution for fluid cow’s milk that is requested by a parent/guardian, but that is not prescribed by a medical authority.

Parts A and D of this form must be completed before the center/home can make a substitution for fluid cow’s milk.

If a center/home chooses to provide such a substitution, they will continue until a parent/guardian requests that the substitution be changed or stopped by completing Form 4-G. The form is available from the center/home.

Part A. Participant, Parent/Guardian & Center/Home Information – To be completed by a parent/guardian or center/home contact

person

Participant’s Name: Date of Birth:

Parent/Guardian’s Name: Parent/Guardian’s Phone:

Center/Home Name: Center/Home’s Phone:

Part B. Prescribed Diet Order – This part must be completed by a medical authority as specified above.

Check ONE:

Disability OR

Food allergy/intolerance or other medical condition that does not rise to the level of a disability

2. Specify the disability, food allergy/intolerance, or medical condition related to the prescribed diet order.

3. If the participant has a disability, what major life activity is affected? Example: Allergy to peanuts affects ability to breathe.

4. Type of Special Diet:

Check if not applicable OR specify the type of special diet (e.g. gluten-free, diabetic, etc.).

12/2015 Child Nutrition & Wellness, Kansas State Department of Education Form 4-B

5. Modified Texture: Not Applicable Chopped Ground Pureed

6. Modified Thickness of Liquids: Not Applicable Nectar Honey Spoon or Pudding Thick

7. Special Feeding Equipment:

Check if not applicable OR list special feeding equipment (e.g. large handled spoon, sippy cup, etc.).

8. Foods to be Omitted and Substituted:

Check if not applicable OR list special foods to be omitted and substituted. If more space is needed, sign and attach additional sheet of paper.

IMPORTANT: For a participant who does not have a recognized disability, the only fluid cow’s milk substitutions allowed by USDA

are: (1) lactose-free fluid cow’s milk or a (2) non-dairy beverage with a nutrient profile equivalent to fluid cow’s milk as specified in

federal regulations. Currently the only beverages meeting these specifications are certain brands of soymilk.

Omit Foods Listed Below: Substitute Foods Listed Below:

9. Medical Authority’s Information

Signature: Title:

Printed Name: Phone: Date:

Part C. Parent/Guardian Permission – To be completed by a parent/guardian

I give permission for the center/home responsible for implementing my participant’s prescribed diet order to discuss my participant’s special dietary accommodations with any appropriate center/home staff and to follow the prescribed diet order for my participant’s CACFP meals. I also give permission for my participant’s medical authority to further clarify the prescribed diet order on this form if requested to do so by center/home.

Parent/Guardian’s Signature: Date:

Part D. Request Substitution for Fluid Cow’s Milk due to Lactose Intolerance, Allergy, Vegan Diet, Religious, Cultural or Ethical Reasons – To be completed by a parent/guardian

Instead of fluid cow’s milk, please provide the participant named in Part A. of this form with the following substitute (Check ONE):

Lactose-free cow’s milk Non-dairy beverage with a nutrient profile equivalent to fluid cow’s milk per federal regulations

Parent/Guardian’s Signature: Date:

Definition of Disability:

Under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA), a “person with a disability” means “any person who has a physical or mental impairment which substantially limits one or more major life activity, has a record of such impairment, or is regarded as having such an impairment.”

Major life activities covered by this definition include caring for one’s self, eating, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working and major bodily functions. The term “physical or mental impairment” includes, but is not limited to, such diseases, conditions, and functions as:

Orthopedic, visual, speech and hearing impairments Cardiovascular, circulatory and heart

Cerebral Palsy, Epilepsy, Muscular Dystrophy and Multiple Sclerosis Metabolic and endocrine

Digestive, bowel and bladder Food anaphylaxis (severe food allergy)

Neurological and brain Intellectual Disability

Respiratory Emotional illness

Cancer Drug addiction and alcoholism Individuals who take mitigating measures to improve or control any of the conditions recognized as a disability are still considered to have a disability and require an accommodation.

This institution is an equal opportunity provider.

Family Support Services Request To Administer Medication

FOR THE PHYSICIAN Please provide all requested information:

Name of Child: ___________________________________________________ Birth Date: ______________________

Weight: ________ Height: ___________ Diagnosis: ____________________________________________________

Medication Allergies: _______________________________________________________________________________

The above named client is to receive the following medication during his/her regular day. Please complete this form for all medications given at home, school and center. A physician's signature is required prior to nursing staff administering any medications, and to verify medications given to client.

Medication: Tylenol (Acetaminophen) Dosage: Weight/Age Appropriate

Purpose:

Requested Starting Date: Now Expected Duration: 1 year from start date

When to Administer: As Needed Special Consideration:

Special Instructions to Administer Medication: ________________________________________________________

Medication: Dosage:

Purpose:

Requested Starting Date: Expected Duration:

Times to Administer: Special Consideration:


Medication: Dosage:

Purpose:




FOR THE PARENT/GUARDIAN Please complete the following:

I hereby certify that (Child’s Name) has previously had at least one dose of the above prescribed medication and did not have an adverse reaction from it. I request that this medication be administered at school as directed above. I understand that Rainbows United, Inc. and any employee of Rainbow United, Inc. who administers this prescription to my child in accordance with written instructions from the physician or dentist shall not be liable for damages as a result of an adverse drug reaction suffered by the student because of administering such drug or because of mislabeled or altered product. I hereby authorize Rainbows United, Inc. personnel to exchange information regarding this request with the above named attending physician and with the pharmacy as identified on the affixed pharmacy label. Signature: ____________________________________________________________ Date: ________________________ Lawful Custodian

Please note: Physician’s signature required on both sides of form if additional medications are listed on other side.

PHYSICIAN’S SIGNATURE: _______________________________________________ Date: ____________________

Form No. 584 (2/3/2012)

Medications Cont’d

Medication: Dosage:

Purpose:




Medication: Dosage:

Purpose:




Medication: Dosage:

Purpose:




Medication: Dosage:

Purpose:




Medication: Dosage:

Purpose:




Medication: Dosage:

Purpose:




PHYSICIAN’S SIGNATURE: _______________________________________________ Date: ____________________

Form No. 584 (2/3/2012)

medication administration modification authorization for ... · i/dd case management agency: ......

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