Adult Day School Registration Form

Adult Day Handbook Confirmation Receipt
Parent/Guardian's Signature*

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General Contact Information
Student Name:*

First NameLast Name
Birth Date*

MonthDayYear
Student Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Legal Guardianship:*

Both ParentsMotherFatherOther
Parent/Guardian's Signature**

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*If guardianship is restricted, you must supply legal documentation.
Parent/Guardian Information
If guardianship is restricted, please upload legal documentation here

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Is the Student their own Guardian?*

No, the student is under 18 and has a parent/guardianNo, the student is over 18 AND has a parent/guardianYes, the student is over 18 and is their own guardian
Parent/Guardian Name*

First NameLast Name
Relationship to Student:*
Is the Parent/Guardian Address Same as Student?*

Yes we live at the same address as student
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Email*
example@example.com
Phone Number (Cell)*

Area CodePhone Number
Alt. Number

Area CodePhone Number

Master Other Contact

First NameLast Name
Master Other Work Phone

Area CodePhone Number
Master Other Cell Phone

Area CodePhone Number
Emergency Contact Information:
Please provide your contact information and complete the rest of this form to indicate any individuals you would like staff to contact and/or release your child to in the event of an emergency in which the parent(s)/guardian(s) cannot be reached. The enclosed form includes permission for individuals other than the parent/guardian to pick up your child from school. Please notify your child’s classroom teacher in advance when your child will be picked up by one of these individuals. Photo identification will be required and only individuals listed on the form will be able to pick up your child. Please indicate at least two individuals that are able to pick up your child other than the parent/guardian.
Emergency Contact #1:
Is Emergency Contact the same as Parent/Guardian?*

NoYes
Name*

First NameLast Name
Relationship:*
Does this emergency contact live with the student?*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number (Cell)*

Area CodePhone Number
Alt. Number*

Area CodePhone Number
Can this emergency contact pick up the student from school?*

Please Click to Enter Emergency Contact #2
Emergency Contact #2:
Name*

First NameLast Name
Relationship:*
Does this emergency contact live with the student?*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number (Cell)*

Area CodePhone Number
Alt. Number*

Area CodePhone Number
Can this emergency contact pick up the student from school?*

Please Click to Enter Emergency Contact #3
Emergency Contact #3:
Name

First NameLast Name
Relationship:
Does this emergency contact live with the student?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number (Cell)

Area CodePhone Number
Alt. Number

Area CodePhone Number
Can this emergency contact pick the student up from school?

Emergency Action Plan Information
Please complete this form regarding your child. This information is used in our Emergency Action Plan (EAP) binders to provide emergency responders information they may need to know should an emergency arise.
Eye Color
Hair Color
Height
Weight
Ethnicity/Race
Race

AsianBlack or African AmericaWhiteAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther
Communication Method (i.e. device, verbal, nonverbal)
Distinguishing Marks (i.e. wears glasses, scars, mole)
Likely Response to a Strangers Approach (i.e. run, say hi, cry, ignore)
Probable Attire (indicate clothes your child typically wears)
Student Significant Behaviors (i.e. physical aggression, eloping, crying)

Parental Consent for Emergency Treatment
Please sign and date the enclosed form granting permission for Turning Pointe Autism Foundation employees and agents to provide and/or arrange for emergency medical treatment for your child.
Physician Name*
Physician Phone Number*

Area CodePhone Number
Physician Fax Number *

Area CodePhone Number
Parent/Guardian Signature *

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Date*

MonthDayYear

Medication Information Log
Please complete the medication log to include all medications your child is currently taking, including any over-the-counter, PRN (as needed) medications such as Tylenol, multi-vitamins, any medications taken outside of school, etc. If any medication changes occur during the year, please notify the nurse.
My child's medication status:*

Yes, my child is taking medicationNo, my child is NOT taking any medication
Please detail the student's current medication in the table below:

Consent to Retain a Copy of the Student’s Final IEP and/or Triannual Evaluation
Turning Pointe Autism Foundation’s CN Day School is an ISBE Accredited Best-Practice institution. The home school district who contracted with us for your student’s placement at Turning Pointe are the primary hosts/owners of all student records as all communications regarding your student while attending Turning Pointe have been submitted to the district and only copies have been maintained in our records. The ISBE guidelines for a student discharging from our program state that all copies of records for the student served are to be either returned to the home school district or destroyed.

As your student enters into our Adult Day Program, we would like to request your permission to retain the copy that we have on file of your student’s final IEP and/or Triannual Re-evaluation.
Please select your consent:*

I DO give my consent to Turning Pointe to maintain a copy of my student’s IEP/Triannual Re-Evaluation records. My signature is below:I DO NOT wish to have my student’s records retained on file for on-going reference.
Parent/Guardian Signature

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Field Trip Consent
Please sign and date the enclosed form granting permission for Turning Pointe employees and agents to provide transportation for your child for community outings, field trips, and participation in Turning Pointe’s swim program. This permission form provides consent for community outings/field trips for the entirety of the school year; however, teachers will provide advance notification of upcoming outings other than swim.
As part of the Turning Pointe CN Day School Program, the school may be incorporating community outings and field trip experiences. The classroom teacher will provide notice prior to the upcoming trip regarding location, time, cost, etc. In addition, students have the opportunity to experience swimming on a consistent basis. If you have any questions about these activities, please contact the classroom teacher.
Parent/Guardian Name*

First NameLast Name
Field Trip Permission:*

Yes, I DO give consent for Turning Pointe CN Day School staff to transport my child for community outings and field trips.No, I DO NOT give consent for Turning Pointe CN Day School staff to transport my child for community outings and field trips.
Swim Program Permission:*

Yes, I DO give consent for my child to participate in the swim program.No, I DO NOT give consent for my child to participate in the swim program.
Parent/Guardian Printed Name*
Parent/Guardian Signature*

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Crisis Management Notification
Turning Pointe utilizes Professional Crisis Management (PCM) procedures, time-outs, calm rooms, and safety equipment to maintain safety. You will be contacted if a time-out or PCM procedure is utilized for your child. Please, sign this form to indicate that you have received notification of Turning Pointe’s use of crisis management systems.
Parent/Guardian Signature*

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Media Release
Please indicate your permission for Turning Pointe Autism Foundation to use media (i.e. photographs, video, work, etc.) of your child for educational and public relation purposes, such as, in brochures, on our website, or in other media-based outlets or forms.

Please note this does not include student pictures on communication devices for educational purposes, as this is an important part of our programming.
Do you agree to a media release for this student?*

Yes, I agreeNo, I do not agree
Do you agree to a release for Class Dojo for this student?

Yes, I agreeNo, I do not agree
Parent/Guardian Signature*

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Occupational Therapy Services
Please indicate whether your child has permission to participate in occupational therapy services.

Based on the sensory needs of your child, our Occupational Therapists may recommend the use of a squeeze machine to augment your child’s sensory diet.
Please Choose One of the Following:*

I do give consent for my child to receive sensory input provided by the Squeeze Machine.I do not give consent for my child to receive sensory input provided by the Squeeze Machine.
Physical education, recreation, and occupational therapy programming includes the use of exercise for the health and well being of our students. Please indicate your consent for your child to use fitness equipment (i.e. treadmill, stationary bicycle, elliptical, swing, etc.) as part of your child’s occupational therapy and physical fitness needs.
Please Choose One of the Following:*

I do give consent for my child to use physical fitness equipment.I do not give consent for my child to use physical fitness equipment.
Please indicate whether your child has permission to participate in the Dog Therapy Program.
Please Choose One of the Following:*

I do give consent for my child to participate in dog therapy.I do not give consent for my child to participate in dog therapy.
Parent/Guardian Signature*

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Sunscreen/Insect Repellent Consent
This form gives Turning Pointe permission to apply or assist in applying sunscreen and/or insect repellent to your child. Turning Pointe reserves the right to request an Authorization of Administration of Medication form completed by the parent and physician if necessary (i.e. sunscreen or repellent is medicated).
*If you would like us to apply sunscreen and/or insect repellent, please provide sunscreen and/or insect repellent with your child's name.
Please Choose One of the Following:*

I DO authorize Turning Pointe to apply/assist in applying sunscreen to my child.I DO NOT authorize Turning Pointe to apply/assist in applying sunscreen to my child.
Please Choose One of the Following:*

I DO authorize Turning Pointe to apply/assist in applying insect repellent to my child.I DO NOT authorize Turning Pointe to apply/assist in applying insect repellent to my child.
Child's Name*

First NameLast Name
Parent/Guardian Signature*

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Health and Communicable Disease Policy
Student Name:*

First NameLast Name
Health and Communicable Disease

School attendance is important; however, your child may need to stay home because they are too sick to effectively learn at school and they might spread a contagious illness to other students. While not all illnesses require exclusion, there are instances when students may be sent home from school. School staff will notify parents/guardians when a student needs to be picked up from school.

Parents are asked to keep their children home OR they will be sent home if an illness or injury results in the following:
- Prevents the student from participating comfortably in academics or activities
- Results in needed care that is greater than school personnel can provide considering the health and safety of your child and other students
- Poses a risk of spread of diseases to others
Please keep your student home in the following situations. If a student is already at school and shows any of the following signs, they may be sent home:
- *Fever (100.4 or deviation from child’s baseline) *Without the use of fever reduction medication
- Vomiting
- Persistent diarrhea
- Rash
- Malaise or a general feeling of being unwell
- Unexplained fatigue
- Sore throat
- Mouth sores
- Eye infections (conjunctivitis or pink eye)
- Difficulty breathing or shortness of breath
- A drastic change in baseline behavior
***In the event that your child displays any of the above symptoms, please keep them home from school. Thank you for your assistance.***

Additionally, please follow the guidelines below:
- Students may return to school once they are symptom-free for at least 24 hours without the use of fever reduction or other symptom relief medication
- Absences due to illness that last 3 or more days need a release from a physician to return to school
- Communicable diseases (i.e. step throat, influenza, conjunctivitis - “pink eye,” chickenpox, mumps, pertussis, measles, rubella, staph infections, scabies, fifths disease, hand, foot, and mouth, impetigo, and head lice, etc.), must be reported to the school
- Confirmed cases of communicable diseases will need a note from a physician to be released to the school
The list of symptoms and communicable diseases is not a complete list and Turning Pointe will make decisions based on the health and safety of everyone. Notice of potential exposure to communicable diseases will be sent home when cases appear in the school. Please be assured that your student’s name will not be released on the notice.
Parent/Guardian Signature:*

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Functional Analysis (FA) Consent
Please review and sign the FA Consent form. This assessment ensures effective programming to support our students.
THE FOLLOWING PROCEDURES MAY BE NECESSARY TO UPDATE YOUR CHILD'S BEHAVIOR PLAN ANNUALLY/AS NEEDED.

Dear Parent,

In order to provide the most effective evidence-based treatment to support your child, it is necessary to identify the environmental variable(s) that are maintaining problem behavior by conducting a Functional Analysis (FA). Functional, or experimental, analyses of problem behavior (Iwata, Dorsey, Slifer, Bauman & Richman, 1982/1994). Research conducted over the last 30 years has shown that this method of assessment is the "gold standard" for identifying the variables that maintain severe problem behavior (e.g., physical aggression). Additionally, research has shown that treatments based on the results of these assessments are much more likely to be effective (Beavers, Iwata, & Lerman, 2013; Hanley, 2012).

The FA will consist of exposing your child to several brief conditions that may occasion problem behavior. This can be compared to the doctor conducting an allergy test (exposing you to allergens) in order to determine what causes a reaction. This will allow us to identify what environmental variables that lead to problem behavior.

Pending your approval, you will be notified prior to the assessment start date by your child's BCBA. Upon your request, the BCBA will contact you with the results of the assessment.

We greatly appreciate your involvement in this assessment. If you have any questions regarding the assessment procedures/process, please do not hesitate to contact Bianca Frost, M.S., BCBA.
Please Choose One of the Following:*

I DO give consent for my child to participate in Functional Analysis.I DO NOT give consent for my child to participate in Functional Analysis.
Supervising BCBA Signature
Parent/Guardian Signature*

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School and Home Agreement
To facilitate constant, honest and respectful communication between Turning Pointe Autism Foundation Programs and Parents/Families/Guardians, the following agreement outlines the responsibilities in improving student outcomes.

Turning Pointe Promises to:

Offer evidence-based best practice methodology in all educational capacities during activities, lessons, community outings, vocational experiences, and behavior management
Collaborate with the student’s entire educational team and work toward progress on goals and program outcomes
Utilize best-practices in the areas of assessment, teaching methodologies, behavior interventions, and overall programming
Communicate to stakeholders (i.e. school district, employer, etc.) and families on a regular basis, including progress on goals, school updates, parent meetings, regular teacher emails and/or home notes
Recruit and offer robust training opportunities for highly qualified specialists and staff
Respect parent/guardian suggestions on student observations appreciating they know their child best
Trust parent/guardian feedback and observations
Develop meaningful relationships that foster independence in the areas of independent living, social communication, and employability skills

Parents/Guardians Promise to:

Remain connected to the school (i.e. via home notes, regular emails, other school communication platforms) with an emphasis on sharing any life, routine or medical changes for the student, and by reading information disseminated by the school
Attend parent meetings and trainings
Remember Turning Pointe specialists and staff design programming for each student to meet their unique individual needs
Support regular attendance, timely arrival, and report any absences or tardiness
Report contagious diseases and symptoms and follow the health and safety policy
Respect Turning Pointe’s team members as professionals fully vested in student success
Trust Turning Pointe assessments and recommendations appreciating their expertise in the field
Establish routines to support learning including healthy sleep schedule, nutrition, grooming/hygiene routines, and vocational routines
Remember that administration, specialists and staff may have different assessment results and intervention plans based on a student in the school environment. An open mind and appreciation that opinion on what is in the best interest of the student may differ across settings. Together, if we embrace these differences and utilize all knowledge about the student, we can improve outcomes.
Turning Pointe Executive Director Signature
Parent/Guardian Signature*

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Peanut and Tree Nut Free Building Notification
To ensure the safety and wellness of all students, we are a peanut and tree nut free school. Life-threatening allergic reactions that require medical attention can occur to individuals with peanut and tree nut allergies. We ask that you assist us in providing a safe school environment by helping us eliminate potential exposure to peanuts and tree nuts and avoid life-threatening allergic reactions.

Please complete the bottom portion to acknowledge that you are aware that Turning Pointe Autism Foundation is a peanut and tree nut free campus. We thank you for your cooperation.
In October 2006, the FDA began identifying coconut as a tree nut. As a result, we are discouraging students and staff from consuming or using anything containing coconut.

Remember to read food labels and ask questions about ingredients before eating food that you have not prepared yourself.
Child's Name*

First NameLast Name
Parent's Name*

First NameLast Name
Parent/Guardian Signature*

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