CROW CREEK TRIBAL SCHOOLS
Dormitory Application
2015-2016
CCTS Residential Program State of Purpose
The Purpose of the CCTS Dorm is to provide a traditional home-living environment to students attending Crow Creek Tribal Schools. We are not a therapeutic dormitory, so we may not be able to meet the need of all students. All student applications will be reviewed by the dormitory committee to determine if the CCTS residential program can meet each student’ residential needs. A waiting list will be as application come in to the CCTS Dorms for the new school year.
Application Deadline
The dorm application deadline is July 26th. Any applications received after this deadline will be considered if space is available.
Attendance in the Dorms
Because we only have space for 50 girls and 50 boys in the new dorms, we want to keep our attendance high throughout the entire year. We hope that the students and their parent/guardian will make a strong effort to be with us for the entire school year once they are accepted. Whenever a student is out of the dorm for 10 consecutive days, they will be dropped from the dorm (as required by BIE) and their name will be placed at the bottom of the waiting list. The next person on the waiting list will be contacted and invited into the dorms. We appreciate your understanding and look forward to providing a safe and enjoyable residential experience for the 2014-2015 school year.
Other Notes:
1. Be sure to have your CHECK-OUT FORM NOTARIZED.
2. Health forms are important to fill out (both off-reservation and local students)
Crow Creek Tribal Schools
2015-2016 Dormitory Application
105 Chieftain Loop, Stephan, SD 57346
Appendix B-Charges for Damages caused by students
The following are amounts which could be charged in the event you son/daughter was to cause damage to the dorm either by intention or as a result of misconduct.
Damage to dorm cause by student:
qBroken Window $100 qHole punch in wall $50 qDoor $300
qWardrobe/Hasp Damage $50 qCombination lock $15-$25 qGraffiti Clean-up $25
qFire Extinguisher Cover $75 qBathroom/Shower Damage $100
Damage to furniture, causing replacement values to be considered: (freight might also be charged). These prices are based on the actual costs of furniture as ordered by BIA.
qWardrobes $485 qBed $295 qMattress $140 qDrawer $140 qDesk $295
qChair $125 qNightstand $310 qDesk/Chair $165 qTable $385 qStool $30
qFoosball Table $530 qRound Table $320 qCoffee Table $180 qEnd Table $180
qBookcase $120 qTable w/Ped & Footrest $365 qPool Table $4,400
qLounge Table $320
I understand that if my son/daughter damages any dorm property, I will be included in the discussion and investigation. I also agree that should my son/daughter be found liable through either misconduct or willful actions, I will be responsible for any reasonable charges, which might include freight.
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Student’s Name Student’s Signature
______
Parent/Guardian Signature Date
Crow Creek Tribal Schools Dorm Application Packet for Students 6/13/11
{The Home Living Specialist will call each parent/guardian to review, prior to approval.}
[Failure to provide an accurate response to all questions can result in denial of application or your child’s immediate release from the CCTS Dorms.]
Section I: Educational History
Student Name: ______Date: ______
Parent/Guardian: ______. Relationship to student: ______
Phone #s: Home ______Cell ______Work ______
Other phone #s for emergencies: ______; ______.
Mailing Address: ______City ______State ______
Check boxes below to indicate previous and current educational placements, if known.
Kind of Placement (check all that apply) / Previous / Most recentRegular Classroom / q / q
Regular Classroom with in-class support and/or accommodations / q / q
Special Education Classroom/Resource Room / q / q
Alternative School / q / q
Treatment Program / q / q
Residential School and Dorm / q / q
Home and/or Hospital-based Instruction / q / q
Not in school – suspended / q / q
Not in school – expelled / q / q
Please describe educational placement(s) checked above:
Section II: Living Situation History
Check boxes to indicate previous and current living situations, if known.
Type (check all that apply) / Previous(Before) / Current
(Now)
One Parent (indicate Mother or Father): / q / q
Relatives / q / q
Foster Care / q / q
Group Home / q / q
Emergency Shelter / q / q
Residential Treatment (non drug/alcohol) / q / q
Drug/Alcohol Residential Treatment Program / q / q
Medical Hospital / q / q
Psychiatric Hospital / o / o
Juvenile Center (JDC) / o / o
Correctional Facility (i.e. Custer) / o / o
Has a child / o / o
Has fathered a child or been pregnant / o / o
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Crow Creek Tribal Schools – Dorm Application Packet for Students
Section III: Behavioral Issues
Student’s Name: ______Date: ______
Note to Parents/Guardians: Your providing accurate information will help us provide your child with the best possible services to help her/him have a successful year in our dorm.
Has the child or youth ever exhibited any of the behaviors listed below? If yes, check those that apply.o Shows strong emotions / o Impulsive / o Stealing
o Extreme sadness / o Anxiety / o Depression
o Runs away / o Mood changes / o Hard time sleeping
o Eating disorder / o Hyperactivity / o Bladder/bowel problems
o Not accepting authority / o Refusal to accept limits / o Argues with others
o Verbal aggression / o Self-injurious behavior / o Persistent school refusal
o Anger towards self / o Anger towards others / o Cutting
o Expressed aggression towards people / o Expressed aggression towards property / o Tends to avoid social contact with others
o Expressed thoughts of suicide / o Shown suicidal behavior / o Suicidal attempts
o A family member or very close friend has committed suicide
o Has a social services case worker / o Extreme withdrawal from family / o Serious sleep disturbance
o Fire setting/fire play / o Animal cruelty / o Problems with the law
o Missed more than 10 days of school last year / o Suspension (out of school) during past year / o Expelled from school during the past two years
o Huffing inhalants (paint, hairspray, glue, nail polish) / o Huffing “dusters” (aerosol air cleaners - to clean key-boards, etc.) / o Huffing alcohol-based products or other aerosol-type products
o Substance abuse / o Experienced trauma / o Inappropriate behavior
o Has been arrested / o Has a probation officer / o Bullying
o Special concerns or counseling help you would like to see for your child: (please list)
New Policy for all dorm students-2013-14 School Year: For your child’s safety parents/guardians must agree with allowing the dorms to test their child for mood altering substances if there is reason for concern. In this cause you will be notifies of the reasons for this concern and the testing results.
I give my permission for my son/daughter to be tested. I understand this is for their safety, and that of the dorms. I also understand that I will be contacted both before and after this testing.
Signature of Parent/Guardian:______
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Crow Creek Tribal Schools – Dorm Application Packet for Students
Section IV: Social History – Counseling Information
Student’s Name: ______Date: ______
[Failure to provide an accurate response to questions can result in denial of application or your child’s immediate release from the CCTS Dorms.]
Has your child received any out-patient counseling or therapy for substance abuse, mental health or behavioral issues? _____Yes _____No
If yes, please identify and describe what kind and have the Counselor or therapist send a report and recommendations to the Dorm Counselor, Crow Creek Tribal Schools Dorms.
Why did they seek counseling? ______
Name & Title of Counselor or Therapist: ______
Address: ______
Phone Number: ______Date(s) of Counseling: ______
Has your child ever received in-patient services treatment program for substance abuse, mental health or behavioral issues? ______Yes _____ No
If yes, please have the treatment program send a report and aftercare recommendations to the Dorm Counselor, Crow Creek Tribal Schools Dorms.
Did they complete this? ____ Yes ____ No Was this helpful? ____ Yes ____ No
Name of Treatment Program: ______
Address: ______
Phone Number: ______Date of Treatment: ______
Has your child ever been arrested? _____ Yes _____ No
Has your child ever received services from a correctional program? ____ Yes ____ No
If yes, explain. ______
Please have the facility send a report & recommendations to the CCTS Dorm Counselor.
Name of Correctional Facility: ______
Address: ______
Phone Number: ______Date of admittance: ______
Does your child have a Social Worker or Probation officer? If so, please provide name and contact information. ______
Has your child ever been arrested or charged with a sexual offense? ____Yes ____No
Has your child ever been a victim of sexual abuse? _____Yes _____No
If yes for either, please describe: ______
______
If yes, has your child/youth been in counseling? ____ Yes ____ No
Section IV: Social History, Continued. Student’s Name: ______
Has your child displayed any anger against others or themselves? ____ Yes ____ No
If yes, please explain. ______
Does your child use “cutting” as a way to solve problems? _____ Yes _____ No
If yes, please explain.
______
______
What is the cutting behavior? (i.e. possibly using a razor to cut their arms.)
______
Has your child missed more than ten days of school during the past school year?
_____ Yes _____ No If yes, please explain: ______
Has your child been expelled during the past school year? _____ Yes _____ No
If yes, please explain:
______
Has your child received an out-of-school suspension during the last school year?
If yes, please explain: ______
Do you have any special concerns for which you would like the counselor to be aware?
______
List any medications your child has been prescribed during the past year:
Name of medication(s) / Dosage / How often taken?______
Parent/Guardian (print) Signature of Parent/Guardian Date
Crow Creek Tribal Schools
SCHOOL/I.H.S. COUNSELING CONSENT FORM
Student’s Name: ______Grade: ______Age:______
CONSENT FOR COUNSELING SERVICES
Confidentiality and Limits to Confidentiality
Trust and honesty are crucial to the development of all therapeutic relationships. Therefore, we place high value on the confidentiality of information you share within you sessions. You should, however, be aware that legal, ethical and licensure requirements specify certain conditions in which it may be necessary for you provider to discuss information about you care with other professionals,. If you have any questions about these limitations, please ask for provider before counseling begins. Such situations include:
· Danger that you may harm yourself or others, or are incapable for caring for yourself.
· Suspicion of abuse of children, elderly or disabled persons
· A Court Order to release you records.
· Your provider may sometime find it necessary to obtain professional consultation I n regards to the course of your care. Consultation regarding your case may be sought periodically with his/her supervisor and other colleagues only when needed. Your providers will inform you when he/she determines consultation is necessary. You identity may or may not be disclose when this occurs.
I give permission for my child to receive counseling services from Crow Creek Tribal School or
through Indian Health Services in Fort Thompson, SD. I understand that this service will be
given if and when my child’s behavior indicates the need. I understand that if I do not give
consent for counseling services from the school or Indian Health Service, I must provide an
outside source for counseling if deemed necessary.
In signing below, I acknowledge that I fully understand what I have read. I understand that I
will have had an opportunity to ask questions as needed, and that I consent for my
son/daughter to participate in counseling with the CCTS School/Dorm and Ft. Thompson I.H.S.
Behavioral Health Program if needed.
______
Student Signature Date
______
Parent/Guardian Signature Date
Crow Creek Tribal Schools
DAY Student Check out Form – 2015/2016
(Dorm students must use the Dorm Check-Out Form when checking out during school.)
It is very important the Parent/Legal Guardian have this form complete and notarized for the safety of our students. Students will not be allowed to check out of the dormitory or school unless they are released to a person whose name appears on this permission form. Any other special circumstances will have to be referred to a Principal, Dormitory Supervisor or Superintendent.
______
Student Name Home Reservation
______
Parent/Legal Guardian Phone # you can be reached at immediately
______
PO Box/Address City State Zip
· I hereby give the following adults permission to check out my son/daughter for week-ends or holidays.
· I understand that these adults must personally pick up the student and sign him/her out from the school (if during school hours) and from the dormitory.
· I understand that off reservation students may not check out to Ft. Thompson and surrounding communities for overnight unless with parents or legal guardian.
(Handwriting must correspond to notarized signatures at bottom of the page)
______
______
______
______
I also give the school permission to seek out adequate housing and transportation for my son/daughter during emergencies.
______
Signature of Parent/Legal Guardian Verified by Notary of the Public
______My Commissions Expires On
SDHSAA FORMS AND I.H.S. INSERTS ARE ATTACHED TO THE NEW STUDENT APPLICATION
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