Short Course Application West Virginia Schools for the Deaf and the Blind

301 East Main Street, Romney, WV 26757 (P) 304.822.4800 (F) 304.822.3370

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Student Information (2 pages)

Press Consent Form

Medical history

Acceptable Use Policy (AUP) is completed for the WVSDB.

Medical Consent Form

Standing Order Medications (3 pages)

Seizure and/or Asthma Action plan (if applicable)

Authorization for the Administration of Medication for EACH medication (to be signed by a doctor)

4. To be completed PRIOR to Short Course Week

______ Memorandum of Understanding completed and signed between the Local School District and WVSDB.

3. Documentation in addition to packet

_____ Copy of current IEP

_____ Copy of Immunization Records

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2. Short Course Application Packet is completed by the Local School District and the Parents toinclude the following:

Admissions Application Checklist The following is a brief description of records, forms, and procedures that need to be completed as part of the application to The West Virginia Schools for the Deaf and the Blind.

1. To which Short Course are you making application? Select as many as are applicable.

September 11-13: Focus on Transition for grades 8 and up only

November 15-17 : Technology Weekend for Grades Pre-K to 12

February 16-21: Braille Challenge/ASL Challenge for grades Pre-K-12

April 1-3: Cane Quest/Deaf Culture for grades Pre-K-12

May 14-17: Prom and Family School Association Day for Grades 6 and up only

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STUDENT INFORMATION FullName

DOB

Middle MM DD YYYY

PARENT OR GUARDIAN INFORMATION Parent/ Legal Guardian

First Middle Last Maiden

Mobile Phone

Work Phone

Home Address:

City, State, Zip Code:

Home Phone

Email

Address:

First Middle LastHome Address:

City, State, Zip Code:

Home Phone

Mobile Phone

Work Phone

Date________________________

Email Address

First

Who has custody and is the legal guardian? Please provide documentation.

Joint Mother Father Other________________________________________________________

If 18 or over, is student his or her own guardian? If no, please provide documentation

YES NO Not Applicable

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LastGender: M F Social Security Number ______________________________________________

Current Grade_______: Current District of Enrollment ______________________________________________

Parent/ Legal Guardian

EMERGENCY INFORMATION Name Relation to Child Home Phone Mobile Phone

Can Pick-Up at Bus Stop

Yes No

Yes No

STUDENT INFORMATIONPlease mark the appropriate exceptionality:___Deaf ____ Hard of Hearing ____DeafBlind ____Blind ___Low Vision

My child learns best through (Please select all that apply):___ Voice ___ASL ___Braille ___Assistive Technology using_________________

Please list any accommodations , including assistive technologies, that your child will need: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Does your child wear:

___ Glasses ___Contact Lenses ___Hearing Aids ___Cochlears/BAHA

Independent Living Skills: Please circle all skills that you know your child may need assistance with while at WVSDB:

Eating Bathing

Dressing Toothbrushing Toileting Orientation & Mobility

Please describe in detail how staff can assist your child with the above skills: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Please list the tasks that your child needs one on one assistance performing: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Cane Putting on Hearing Aids

Press ConsentChild’s Name:_____________________________________________________________________________________

PRESS RELEASE AND DATA COLLECTION I (we) hereby grant the West Virginia Schools for the Deaf and the Blind permission to photograph, videotape,

or otherwise depict my child, and to publish any such depiction along with his/her name and age in connectionwith any publicity program or professional activity.

I (we) understand that any depiction may be used in connection with newspapers, television, website, radioprogram, motion pictures, school publications, professional journals, and in other proper circumstances.

Consent for photographing and video may be used for medical purposes for documentation of accident orinjury. I (we) give permission for the West Virginia Schools for the Deaf and the Blind to collect and submitdata concerning my child which is required by deferral and state agencies for reporting purposes.

SPECIAL INSTRUCTIONS Please include any special instructions below

Your signature below indicates consent for all sections above unless section(s) is/are otherwise initialed.

Parent or Guardian Signature Date Parent or Guardian Signature Date

MEDICAL HISTORY Does your child have any special dietary requirements?

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Altered Food Consistency:

(pureed, mechanical soft, chopped meats,

etc.)

_____Thickened

Liquids _____

Food Tolerance or Allergy (list

below) _____ NutritionalSupplement

_____ Sleep Walker _____ Scared of Dark _____ Anxiety Problems

ALLERGIES Food Name Reaction

Medication Name Reaction

Other Allergies Reaction

Is child on regular medication? Yes No

Please list all medications your child is currently taking:

Note: If YES, Administration of Medication Form must be filled out by a physician for EACH medication. This is a state requirement and the completion of the form allows the school to administer the prescribed medication. Parents must sign the form and a physician must complete the top of the form. A medication form must be completed for any prescription or long term over the counter medication during the school year. If a child is to carry their own inhaler and use as needed, a physician must authorize the self-administration of that medication. Medication must be in the original prescription bottle. Most pharmacies will give a second prescription bottle upon request to be sent to school.

Please inform the Infirmary staff of any change in the child’s health so that they are better able to care for the student. The Health Services staff can be reached at 304-822-4831.

Other diagnoses, illnesses, and operations:

MEDICATIONS

WVSDB Short Course Acceptable Use of Technology Resources

It is the belief of WVSDB Short Course that the educational benefits to students through access to the Internet far exceed and potential disadvantages of such access. Access to the internet is given as a privilege to students who agree to act in a responsible manner. We require that students and their parents/guardians read and accept the following rules established by West Virginia Board of Education Policy 2460 and WVSDB Short Course.

As a responsible technology user:

I will use all technology only for educational purposes and objectives established by my teachers. I understand that my technology will be monitored.

I will only access programs and equipment I am authorized to use.

I understand that I may access email at school only through my state given email account. I may not access my personal email account while using WVSDB technology.

I understand that information obtained online is, unless specified, private property; therefore, I will not plagiarize information received and will adhere to copyright laws.

I will respect and not attempt to bypass the network security measures put into place by WVSDB and the WV Department of Education.

I will not divulge personal information of others or myself.

I will not install or add any device to the school computer or network.

I will only use my usernames and passwords. I will not share this information with others.

I will not participate in direct electronic communications such as but not limited to blogs, wikis, text messaging, chat rooms, and instant messaging unless assigned for a specific educational purpose and under the direct supervision of a teacher.

I understand that these guidelines include personal devices such as cell phones, video cameras and other electronic technologies. I will not use such devices for cheating, taking inappropriate pictures, copying of materials that could be used for cheating, text messaging, engaging in cyber bullying, or any inappropriate communication. I further understand that if I receive any of the above mentioned items, I am required to report it to a teacher immediately.

I understand that I, as the technology user, am personally responsible for my actions in accessing and utilizing the schools' technology resources.

I understand that if I lose, steal, neglect to return or intentionally break a device, my parents can be held financially responsible for the replacement cost of the device.

I understand that the use of technology at WVSDB is a privilege, not a right.

I further understand that violations of these rules can result in the loss of technology access at WVSDB.

WVSDB Short Course Acceptable Use of Technology Resources

As a user of the WVSDB computer network, I agree to comply with WV Board of Education Policy 2460 and the above policy. Should I commit any violation, I accept responsibility for my conduct and understand that I will lose technology access privileges at my school.

STUDENT’S NAME: ________________________________________________________

STUDENT’S SIGNATURE: ________________________________________________________

(If student is unable to sign, please write N/A)

DATE: ________________________

FOR PARENTS/GUARDIANS OF MINORS: As a parent or legal guardian of the above signed student, I have read and discussed these regulations with my child. I understand that WVSDB and the WV Department of Education have taken precautions to minimize objectionable material. However, I recognize it is impossible to restrict access to all controversial materials. I understand that it is the responsibility of my child to restrict his/her use to the set guidelines.

I also understand that if my child is to lose, steal, neglect to return or intentionally break a device, I can be held financially responsible for the replacement cost of the device.

PARENT/GUARDIAN’S NAME:___________________________________________________

PARENT/GUARDIAN’S SIGNATURE:_______________________________________________

DATE: ________________________

**Policy 2460 can be found on the WVSDB website: https://www.wvsdb2.state.k12.wv.us/

Technology Contact Signature: _________________________________________

Date Completed Form is Received: ________________________________________

Short Course needs: _________________________________________________________ _________________________________________________________

I, _______________________, parent/legal guardian of ___________________________, do hereby consent to give proper medical attention to my child by West Virginia Schools for the Deaf and the Blind’s Health Services, contracted medical provider, or emergency services as indicated below:

INSTRUCTIONS: If you have read and consent to each statement below, please initial on the line. Otherwise, leave blank

1. ____ I give consent that WVSDB’s Health Services and appropriately trained staffadminister medication and provide treatments that the contracted medical providerdeems necessary. I understand that staff will make at least three (3) attempts to contactme to get verbal permission to administer medication or treatment as ordered by thecontracted medical provider. I understand in the event that I am unreachable, that thisconsent or authorization give executive consent so that there is no delay in treatment.

2. ____With the exception of an extreme emergency, I give consent for WVSDB staff toconsent to care that is necessary for the welfare of my child in an emergency if I am notreasonably available by telephone to give consent. I understand every attempt will bemade for me to be contacted prior to and after the situation. I understand that afterthree (3) attempts, this is considered a sufficient number of calls that has been made ingood faith.

3. ____ I give consent for WVSDB staff to accompany my child to medical clinics held on- oroff-campus and give/receive information concerning my child to medical staff of saidclinic, during my absence.

4. ____ I understand that there may be costs associated with treatments and medicationprescribed by the contracted physician are the responsibility that of the parents/guardian.

5. ____ I consent that when WVSDB staff is attempting to make contact me and areunsuccessful, that emergency contacts be contacted.

_____________________________________________________________________________ Print Name Parent/Guardian Signature

Medical Consent Form

Date

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Name: (Last) ____________________________, (First) __________________________, Middle _________________

Date of Birth: ____/_____/______

Standing Order Medications: Many of the children at WVSDB are residential and reside with us for extended periods of time. Because of this, it is necessary for Health Services (Infirmary) to keep medications on hand to treat the children during acute and short-term illness or injury. Below you will find a list of medications that are stocked in the Health Service Office and the applicable uses. Please review the list and indicate yes or no. This form gives permission for the licensed nurses employed by the school to determine necessity and administer these medications. It is not necessary for the student to be examined by a physician prior to administration. Dosage of medication will be based on age or weight.

Medications Yes No

Benadryl (Diphenhydramine) - is an antihistamine used to treat allergy symptoms. These symptoms include sneezing, watery eyes, runny noses, itching, hives and rash. This medication is fast acting and can be given as the first line of defense against allergic reactions. Benadryl can cause severe drowsiness and will be avoided during school hours unless deemed necessary.

Cold and Cough Medications – Cough medications are made up of four main ingredients. These ingredients are combined together or in different combinations to treat different symptoms.

1. Brompheniramine Maleate is an antihistamine that is used to provide relief of sneezing; itchy, watery eyes; itchy nose or throat; and runny nose because of hay fever (allergic rhinitis) or other upper respiratory allergies.

2. Dextromethorphan HBR is a cough suppressant that works by slowing the cough reflex. It is marketed alone as Delsym and used alone to treat dry coughs in the absence of congestion.

3. Phenylephrine HCL is a nasal decongestant that relieves sinus congestion and discomfort caused by colds, allergies, and hay fever. It works by shrinking the blood vessels in the sinus passages and reducing swelling. It is often referred to as Sudafed PE (not be confused with pseudoephedrine - Sudafed).

4. Guaifenesin is an expectorant and is used to loosen congestion in the chest and throat. It is marketed alone as Mucinex.

Claritin (Loratidine) – is given to treat allergy symptoms. It is an antihistamine used to treat symptoms such as sneezing, watery eyes, and runny nose. It is usually given for a 10 day period. If the medication results in improvement and symptoms return after medication is discontinued, it may be suggested that the student obtain authorization from a family physician to be medicated on a regular basis. This medication is non-drowsy.

Gas-X (Simethicone) – is administered to reduce bloating, discomfort and pain caused by excessive gas in the stomach or intestines.

Mylanta (Alumina, Magnesia, Simethicone) – is an anti-acid / anti-gas used as a treatment for heartburn, acid reflux, and reflux.

Imodium (Loperimide) – is used to treat acute or chronic diarrhea. It works by slowing the digestion so that the small intestines have more time to absorb fluid and nutrients from the foods that are eaten. It is only given when the diarrhea is excessive and/or there is an increased risk of dehydration.

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Milk of Magnesia (Magnesium hydroxide) - is a saline laxative used on a short – term basis to treat occasional constipation. It is indicated when a child has had no bowel movement for three or more days and presents with complaints of abdominal pain, abdominal distention, restlessness or other indicators that constipation is causing discomfort.

Dramimine (Dimenhydrinate) – is used to treat nausea and motion sickness. This medication will not be given for nausea caused by illness unless the vomiting is excessive and risk for dehydration is present.

Motrin (Ibuprofen) – is administered for the treatment of fever/pain. Ibuprofen is also an anti-inflammatory. This medication will be the first choice for injuries that have resulted in swelling of the soft tissue.

Tylenol (Acetaminophen) – is administered for the treatment of pain/fever. It is the first choice for pain/fever if there is no inflammation involved.

Chloraseptic Throat spray – used to treat minor sore throats with no other symptoms.

Sore Throat Lozenges / Cough Drop – given to ease the discomfort of a sore throat and throat irritation responsible for cough.

Orajel (Benzocaine) – used topically to treat pain related to tooth pain or cold sores.

Gly-oxide - is an oral antiseptic to cleanse the mouth as needed.

Ear drying agent – the main ingredient is isopropyl alcohol and is used to dry the fluid from the ears related to swimming, bathing or other water related activities.

Irritation Relief Eye drops –used to relieve redness and itchy watery eyes related to allergies or exposure to other irritants

Saline Nasal Spray –Treating dry or irritated nasal passages caused by colds, allergies, and low humidity. Works by moistening the nasal passages and mucus.

Hydrocortisone Cream – used for the temporary relief from itching associated with minor skin irritations, inflammation, and rashes due to eczema, insect bites, poison ivy, poison oak, poison sumac, and other environmental irritants.

Triple Antibiotic Ointment – applied topically to prevent infection in minor cuts, scrapes, and burns.

A & D Ointment – used topically to treat and protect from diaper rash and chapped skin.

Desitin (Zinc Oxide) – used topically to treat and protect the skin (primarily for diaper rash).

Burn Cream with Lidocaine – Used topically to relieve pain associated with minor burns and provide protection from infection.

Calamine Lotion – used topically to relieve itching related to poison ivy, oak, sumac, and insect bites. Dry properties also accelerate drying process.

Notes: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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The following documents are to be returned with this form. Please mark them indicating completion. Please contact the Health Service Office (304-822-4830) with any questions or concerns. ___ Copy of medical and/or insurance cards

___ Copy of current immunization records

___ Medical Consent Form

___ Emergency Action Plans (Any student with a diagnosis of Asthma, Serious Allergic Reaction, Seizures, and/or

Diabetes – these forms should be on file at the student’s home school – copies of these documents can be forwarded

to our office. )

I have read this information and verify that I have given complete information to the best of my ability. I understand that this information will be reviewed and if further documentation or information is needed, I will provide the information in a timely manner. I understand that failure to provide the requested information, may result in the inability of my child to attend WVSDB until documentation is complete.

I give permission for the West Virginia School for the Deaf and the Blind to administer the medications and treatments indicated above. I understand that the medications above have been reviewed and authorized by the School Physician. I understand that these medications will be given only after assessment and authorization by a Licensed Nurse and that I will be contacted as noted. I also understand that I am responsible for supplying any Over the Counter Medication that my child uses on a regular basis or for an extended period of time. I also understand that if my child has a dye or flavoring allergy that would prevent them from taking common medication or if they cannot take any or all of the medications above, that I am responsible for supplying a substitute medication if needed. Please sign and return this completed form indicating that you have read and understand all the above information.

Signature of Parent/Guardian: __________________________________________________ Date: _______________

Emergency ResponseA “seizure emergency” forthis student is defined as:

Seizure Emergency Protocol(Check all that apply and clarify below)

❒ Contact school nurse at__________________________❒ Call 911 for transport to __________________________❒ Notify parent or emergency contact❒ Administer emergency medications as indicated below❒ Notify doctor❒ Other ________________________________________

Basic Seizure First Aid• Stay calm & track time• Keep child safe• Do not restrain• Do not put anything in mouth• Stay with child until fully conscious• Record seizure in logFor tonic-clonic seizure:• Protect head• Keep airway open/watch breathing• Turn child on side

A seizure is generallyconsidered an emergency when:• Convulsive (tonic-clonic) seizure lasts

longer than 5 minutes• Student has repeated seizures without

regaining consciousness• Student is injured or has diabetes• Student has a first-time seizure• Student has breathing difficulties• Student has a seizure in water

Seizure Action Plan Effective Date

Physician Signature ___________________________________________________ Date _________________________________

Parent/Guardian Signature _____________________________________________ Date _________________________________

This student is being treated for a seizure disorder. The information below should assist you if a seizure occurs duringschool hours.

Student’s Name Date of Birth

Parent/Guardian Phone Cell

Other Emergency Contact Phone Cell

Treating Physician Phone

Significant Medical History

Special Considerations and Precautions (regarding school activities, sports, trips, etc.)Describe any special considerations or precautions:

Basic First Aid: Care & ComfortPlease describe basic first aid procedures:

Does student need to leave the classroom after a seizure? ❒ Yes ❒ NoIf YES, describe process for returning student to classroom:

Does student have a Vagus Nerve Stimulator? ❒ Yes ❒ No If YES, describe magnet use:

Seizure Type Length Frequency Description

Seizure triggers or warning signs: Student’s response after a seizure:

Seizure Information

DPC772

Treatment Protocol During School Hours (include daily and emergency medications)Emerg. Dosage &Med. ✓✓✓✓✓ Medication Time of Day Given Common Side Effects & Special Instructions

Copyright 2008 Epilepsy Foundation of America, Inc.

Asthma Action Plan for Home and School

Name _____________________________________________________________________________________________________________________ DOB ______ /______ /____________

Severity Classification Intermittent Mild Persistent Moderate Persistent Severe Persistent

Asthma Triggers (list) _________________________________________________________________________________________________________________________________________

Peak Flow Meter Personal Best _______

1-800-LUNGUSA | LUNG.org

School Nurse The student has demonstrated the skills to carry and self-administer their quick-relief inhaler, including when to tell an adult if symptoms do not improve after taking the medicine.

Name _____________________________________________________ Date _____________ Phone (_______) _______-____________ Signature ________________________________________________

Parent/Guardian I give permission for the medicines listed in the action plan to be administered in school by the nurse or other school staff as appropriate. I consent to communication between the prescribing health care provider or clinic, the school nurse, the school medical advisor and school-based health clinic providers necessary for asthma management and administration of this medicine.

Name _____________________________________________________ Date _____________ Phone (_______) _______-____________ Signature ________________________________________________

Healthcare Provider

Name _____________________________________________________ Date _____________ Phone (_______) _______-____________ Signature ________________________________________________

School Staff: Follow the Yellow and Red Zone instructions for the quick-relief medicines according to asthma symptoms. The only control medicines to be administered in the school are those listed in the Green Zone with a check mark next to “Take at School”.

Both the Healthcare Provider and the Parent/Guardian feel that the child has demonstrated the skills to carry and self-administer their quick-re-lief inhaler, including when to tell an adult if symptoms do not improve after taking the medicine.

Please send a signed copy back to the provider listed above.

Green Zone: Doing Well

Symptoms: Breathing is good – No cough or wheeze – Can work and play – Sleeps well at night Peak Flow Meter ________ (more than 80% of personal best)

Control Medicine(s) Medicine How much to take When and how often to take it Take at ______________________________ __________________________ _______________________________________________ Home School ______________________________ __________________________ _______________________________________________ Home School

Physical Activity Use albuterol/levalbuterol _____ puffs, 15 minutes before activity with all activity when the child feels he/she needs it

Red Zone: Get Help Now!

Symptoms: Lots of problems breathing – Cannot work or play – Getting worse instead of better – Medicine is not helping Peak Flow Meter ________ (less than 50% of personal best)

Take Quick-relief Medicine NOW! Albuterol/levalbuterol _____ puffs, ___________________________________________ (how frequently)

Call 911 immediately if the following danger signs are present • Trouble walking/talking due to shortness of breath • Lips or fingernails are blue • Still in the red zone after 15 minutes

Yellow Zone: Caution

Symptoms: Some problems breathing – Cough, wheeze, or chest tight – Problems working or playing – Wake at night Peak Flow Meter ________ to ________ (between 50% and 79% of personal best)

Quick-relief Medicine(s) Albuterol/levalbuterol _____ puffs, every 4 hours as needed

Control Medicine(s) Continue Green Zone medicines

Add ___________________________________________________ Change to ____________________________________________________

The child should feel better within 20–60 minutes of the quick-relief treatment. If the child is getting worse or is in the Yellow Zone for more than 24 hours, THEN follow the instructions in the RED ZONE and call the doctor right away!

Authorization for the Administration of Medication PHYSICIAN SIGNATURE REQUIRED

Student’s Name: Date:

Date of Birth: Parent’s Phone Number:

Parent’s Request/Approval for Administration of Medication at School

Signature:

An authorization of medication form must be completed at the beginning of each school year. If changes in medication or dosage occur, a new form must be completed. Please use one form for each medication.

Diagnosis:

Name of Medication: Dosage: Frequency of Administration:

Method of Administration:

Side Effects:

Allergies:

Comments and/or other instructions, permission to carry inhaler:

PHYSICIAN’S INFORMATION Physician’s Name Printed: ____________________________________________________________________________

Physician’s Signature: _____________________________________________ Date: ____________________

Physician’s Address ____________________________________________________________________________

City: _________________________ State: ___________ Zip Code: ____________________

Disclaimer: No party is held liable should the WVSDB Short Course be cancelled or the student is unable to attend; in that case, the student will be expected to attend his or her home school. This agreement may not be introduced in any proceeding or matter as evidence of admission of wrong doing, or culpability or of the validity of any claims, whether asserted or unasserted

MEMORANDUM OF UNDERSTANDING

West Virginia Schools for the Deaf and the Blind Short

Course Program (SCP)

Student Name:___________________________________________________________________________________________

Local Education Agency (District) Name and Mailing

Address:_________________________________________________________________________________________________

________________________________________________________________________________________________________

This agreement is between The West Virginia Schools for the Deaf and the Blind, hereinafter, called WVSDB, and

the Local Education Agency, hereinafter called the District. The purpose of this agreement is to make clear the

collaborative roles and responsibilities of both parties, namely WVSDB and the District in WVSDB Short Course

Program. The term of this agreement will include all Short Course Programs for the 2019/2020 school year. Both

parties understand that this agreement may be modified or revised through written amendments, or by mutual

consent. This agreement assumes the student enrolled in the District is able to be housed and participate in the

Short Course Program (SCP) as part of the current instructional and residential programming of WVSDB.

JOINT RESPONSIBILITIES

1. The WVSDB and District enter this affiliation for the purpose of providing instructional and cultural

opportunities for students with vision and/or hearing impairments.

2. WVSDB and the District will comply with all Federal and State laws and regulations prohibiting

discrimination.

RESPONSIBILITIES OF THE DISTRICT

1. The District will provide appropriate academic work the student will miss during SCP.

2. The District will pay $100 to WVSDB for round trip transportation not to exceed $1500 total for the

district per academic year.

3. The District will collaborate with the WVSDB Chief Academic Officer and WVSDB Director of Outreach to

ensure adherence to WVBE Policy 4110.

4. The District will confirm with the Director of Outreach one week prior to the scheduled SCP that the

student will be attending.

RESPONSIBILITIES OF WVSDB

1. WVSDB will provide housing and meals during SCP.

2. WVSDB will make available transportation for the student to and from WVSDB for the SCP for a cost.

3. WVSDB will collaborate with the District’s attendance director to ensure adherence to WVBE Policy 4110.

4. WVSDB will ensure the safety and security of the student while on campus or participating in an approved

activity.

5. WVSDB will provide a summative report within two weeks of the commencement of the SCP experience

for the District and the parent/guardian.

District: ____________________________________________________ _________________ Printed Name Signature Date

Email:_______________________________________________

WVSDB: ____________________________________________________ _________________ Printed Name Signature Date