Adult Orientation Form

Emergency Contact Information
First Emergency Contact Person*

First NameLast Name
First Emergency Contact Relationship to You*
First Emergency Contact Phone Number*

Area CodePhone Number
Does this emergency contact reside in the same household with you?*

YesNo
Second Emergency Contact Person*

First NameLast Name
Second Emergency Contact Relationship to You*
Second Emergency Contact Phone Number*

Area CodePhone Number
Does this emergency contact reside in the same household with you?*

YesNo
In case of emergency, illness, or accident, the following OPTIONAL information will be kept in your SoMoTech student file:
Family Physician (doctor or nurse practitioner)

First NameLast Name
Phone Number

Area CodePhone Number
Address

CityState / Province

Postal / Zip Code
Please list any medications you are presently taking:
Name of Insurance Carrier:
Insurance Policy Number:
Name of Policy Holder:
Relationship to You (if other than yourself):
By signing this form, I agree that the information provided is complete and accurate to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
Date

Safety Practice for Career and Technical Education Program
I understand that I am enrolling in a Career and Technical Education program and will, as part of a shop or lab experience, operate equipment and supplies. It is understood that each student will be given proper instruction, both in use of the equipment and in correct safety procedures concerning it, before being allowed to operate it him/herself. Therefore, I agree to the following Safety Pledge:*

I agree to follow all safety rulesI agree never to use a machine without first having permission from the instructorI will report any accident or injury to the instructor immediatelyI understand that violation of safety procedure may be grounds for my termination from the program
Date*

MonthDayYear
Date
Signature

Clear

Declaration of Intent for Adult Students

By signing this Declaration of Intent, I understand that the following regulations apply to adult students in vocational programs. All programs at SoMoTech are offered in compliance with our non-discrimination policy as found in the Adult Education Handbook.
1.       The student agrees to continue training for the full term of the course.

2.       Students are responsible for textbooks and equipment issued by their instructor. If any items are lost or simply not returned, replacement cost will be paid by the student.

3.       Regular attendance is required.

1. Students may be eligible to have up to 10% of the hours in a program per period as excused absences. In a 900-hour program, this would equate to 45 hours of instruction per half.

2. An excused absence is considered one that is unforeseeable, unavoidable, and/or unusual. Examples may include: illness, disability, hospitalization, funeral, or religious observances. Each excused absence will require documentation to the main office prior to approval.

3. Students must make up ALL unexcused absences.

4. If more than 10% excused absences per half of course the student must:

A. Make-up additional time with documentation required. Make-up time must be completed during the same half of student’s course in which the absence occurred.

EXAMPLE – Terry is enrolled in a program of study that consists of 900 clock hours. Terry’s program is divided into two halves, each containing 450 clock hours of study. During the first half of her program, Terry is involved in an accident and misses 62 hours of school. With the proper documentation, 45 of those hours can be approved as excused by the office. Terry must make up 17 hours of school prior to completion of the 450th clock hour of her program.

B. The student is responsible for making arrangements for make-up time and completing the documentation. Attendance forms are available at www.scccwp.edu or at the SoMoTech Main Office and should be turned in to your instructor.

5. In the event of inclement weather on a scheduled day, SoMoTech may, at its sole discretion, designate the day as an excused absence. All allotted excused absences per half may be utilized according to this rule.

6. This policy represents the minimum standard of Southern Missouri Technical Institute. Programs and instructors may establish expectations that exceed this standard. Any changes to this policy by a program or instructor must be on file in the main office and established in the program handbook or course syllabus and distributed at the beginning of the program.

7. EXCESSIVE ABSENCES: Any student who (without PRIOR arrangements through SoMoTech administration) misses five consecutive days or exceeds 20% of the program hours per payment period may be dismissed from the program. The “20% Rule” takes both excused and unexcused absences into consideration.

4.       I acknowledge the Southern Missouri Technical Institute Adult Student Handbook is available under the Current Students tab at www.scccwp.edu.

5.       The School carries NO accident or health insurance. Each student is individually responsible for costs should medical attention be necessary. (Student is required to complete and sign the Student Agreement Release and Acknowledgement of Risk form.)

6. SoMoTech and/or West Plains R-VII Schools may use my photo and/or likeness in program advertising and/or other promotional purposes.
Signature*

Clear
Date*

MonthDayYear
Date

Revised Statutes of Missouri

Chapter 170-Instruction-Materials and Subjects (RSMo 170.005 & 170.007)
Eye protection required, when.

170.005. Every student, teacher and visitor is required to wear an industrial quality eye protective device when participating in or observing any of the following courses in schools, colleges, universities or other educational institutions:

(1) Vocational, technical, industrial arts, chemical, or chemical-physical shops or laboratories involving exposure to the following: Hot molten metals, or other molten materials; milling, sawing, turning, shaping, cutting, grinding or stamping of any solid materials; heat treatment, tempering, or kiln firing of any metal or other materials; gas or electric arc welding, or other forms of welding processes; repair or servicing of any vehicle; caustic or explosive materials;

(2) Chemical, physical, or combined chemical-physical laboratories involving caustic or explosive materials, hot liquids or solids, injurious radiations or other hazards not enumerated.

(L. 1976 S.B. 519 § 1)

Industrial quality eye protective devices defined.

170.007. As used in sections 170.005 to 170.009 "industrial quality eye protective devices" means devices meeting the standards of the American National Standard Practice for Occupational and Educational Eye and Face Protection, Z87.1-1968, and subsequent revisions thereof, approved by the American National Standards Institute, Inc.

(L. 1976 S.B. 519 § 2)

I have read the state laws above and agree to abide by all provisions of the law. I also agree to pay the purchase price if goggles or glasses are lost or damaged.
Signature*

Clear
Date*

MonthDayYear
Date

Student Agreement Release and Acknowledgement of Risk
In consideration of me being permitted to participate in any activity organized, administered, or sponsored by the Southern Missouri Technical Institute (SoMoTech) of West Plains Schools, I agree that:

I understand that some classes by nature involve certain risks (for example: shop, mechanical, construction, allied health, or culinary arts oriented classes). These risks may result from my own actions or inactions, the actions or inactions of others participating in the activity or class.

I understand the nature of the classes and activities, and acknowledge my experience and capabilities, and represent and warrant that I am qualified and physically able to fully participate in such activities. There may be other risks either not known to me or not readily foreseeable at this time and I fully accept and assume all of such risks and all responsibility for any losses, costs, expenses, liabilities, and damages incurred as a result of or in connection with my participation in any way in classes or activities sponsored by Southern Missouri Technical Institute (SoMoTech).

I understand that SoMoTech does NOT provide any insurance coverage for my person or my property. I acknowledge that I am responsible for my safety and my own health care needs, and for the protection of my property. In exchange for allowing me to participate in the SoMoTech classes, activities, and events, I agree to release from liability, agree to indemnify, and hold harmless the SoMoTech, and any SoMoTech agent or employee acting within the scope of their duties, for any injury to my person or damage to my property.

This Release shall be binding upon myself, successors in interest, and / or any person(s) suing on my behalf.

I have read the statement in this document. I agree with its terms and have voluntarily signed it. I understand that this document is complete unto itself and that any oral promises or representations made to me concerning this document and / or its terms are not binding upon the SoMoTech, its administrators, agents and / or employees.

I UNDERSTAND THAT THIS IS A LEGAL DOCUMENT. I HAVE READ AND UNDERSTOOD THIS RELEASE AND I UNDERSTAND ALL ITS TERMS. I EXECUTE IT VOLUNTARILY AND WITH FULL KNOWLEDGE OF ITS MEANING AND SIGNIFICANCE.
Signature*

Clear
Date*

MonthDayYear
Date

Technology Acceptable Use Agreement
I agree to abide by the West Plains R-VII District Electronic Communications System Guidelines, and I understand that any violation of the regulations is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked, disciplinary and/or legal action may be taken.*

YesNo
Signature*

Clear
Date*

MonthDayYear
Date

SoMoTech Program Financial Agreement
I have read, understand, and agree to the maximum program cost available at www.zizzers.org/tuition.*

YesNo
If I have not already, I agree to contact the SoMoTech Financial Aid Office to discuss my payment arrangements (which may include state or federal grants or loans).*

I have already been in contact with the Financial Aid OfficeI will contact the financial aid office prior to the first day of class
I agree to be personally responsible for the full amount listed up to the Maximum Program Cost. If aid is received from any source or a credit is issued based on prior education or personal purchases (i.e. books), that amount will be deducted from my account.*

YesNo
Signature*

Clear
Date*

MonthDayYear
Date

Adult Education Handbook Policy Agreement
I have read, understand, and agree to the policies contained in the Southern Missouri Technical Institute Adult Education Handbook (located at www.somotech.edu under the Current Students tab). Furthermore, I specifically read, understand, and agree to the following handbook sections: Insurance (p.19), Attendance (p.19), Safety (p.20), FERPA (p.24), and the AUP (p. 32).*

YesNo
Signature*

Clear
Date*

MonthDayYear
Date
Final Submit

Clicking submit below will complete your orientation process.
Should be Empty:

SoMoTech Adult Program Orientation

Student Information Form

Emergency Contact Information

Safety Practice for Career and Technical Education Program

Declaration of Intent for Adult Students

Revised Statutes of Missouri

Student Agreement Release and Acknowledgement of Risk

Technology Acceptable Use Agreement

SoMoTech Program Financial Agreement

Adult Education Handbook Policy Agreement

Final Submit