Lakeside Academy Application

Lakeside Academy Application
Applicant's Information:
Name:*

First NameMiddle NameLast Name
Nickname(s) if any:
Gender:*

MaleFemale
Date of Birth:*

MonthDayYear
Date
Age:*
Height:*
(ft) (in)
Weight:*
(lbs)
Social Security Number:*
Permanent Resident Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Permanent Resident County*
My Child Mainly Needs Help With: (Check All That Apply)*

Alcohol/Drug UseBehaviorMental HealthSchoolOther
Applicant's Level of Motivation:*
(1 to 5, 5 being high)
Motivating Factors:*

Applicant's Insurance Information:
Does your child have medical insurance?*

YesNo
If yes, please provide the following information:
Insurance Provider:*
Member ID Number:*
Policy Holder's Name:*
Group Number:*
Policy Holder's Date of Birth:*

MonthDayYear
Date
PMI Number:*
Insurance Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone:*
Please enter a valid phone number.
Do you have secondary insurance?*

YesNo
Important Note:

This is for supplemental medical needs while in the program. (i.e. doctor’s visits, prescriptions, etc.) Not all insurance plans cover out-of-state clinics and services. If deemed necessary, a student may need to be seen by a local clinic while in the program. If insurance does not cover the medical visit, parents will be billed directly by the clinic for services

In your own words, tell us why you want your child to come to Lakeside Academy and the main issues you believe your child needs to deal with while in the program pertaining to the following areas:
Substance Use Concerns:*
Mental Health Concerns:*
Behavioral Concerns:*
Educational Concerns:*
Criminal/Legal Concerns:*
Family (and/or Interpersonal) Concerns:*
Additional Concerns (Please List):*
Initial*

Powered by Jotform SignClear
Initial

Powered by Jotform SignClear

Reviewed Medications

The following medications are reviewed at Minnesota Adult & Teen Challenge due to their interference with the recovery process. Examples of reviewed medications include, but are not limited to, the following:
Medical Marijuana
Medications used Specifically for Weight Loss
Muscle Relaxants
Stimulant Medications
Performance Enhancing Steroids/Supplements, or Herbal Supplements
Essential Oils
Scheduled/Controlled pain relievers, unless pre-approved
Antabuse
Medication Assisted Treatment (MAT)

The use of medications in combination with counseling, and behavioral therapies.
Sleep Aids

Melatonin can be taken as a specific sleep aid and clients with a psychiatric diagnosis may use mental health medications that also treat sleep disturbances.
Important Note:

Minnesota Adult & Teen Challenge has an approved list of OTC medications that clients may purchase on their own.

Voluntary Compliance with Faith Based Activities

Lakeside Academy is a faith-based program that is based upon Christian principles and practices. If you do not want your son to participate in this program and follow the requirements listed below, please contact our admissions department and we will provide a referral list of other programs that may better meet your needs. If you object to the spiritual education model utilized by Lakeside Academy and object to the religious character of this organization, Federal law gives you the right to a referral to another provider. The referral, and your receipt of alternative services, must occur within a reasonable period of time after you request them.
Please read each item carefully and initial your acceptance to each program requirement.
Upon admittance to Lakeside Academy, I understand the following (please initial each line):
My child will participate in daily devotions, Bible reading, and prayer.*

Powered by Jotform SignClear
My child will participate in lecture classes, individualized study courses, group counseling, individual counseling, and other program components that are based on Christian principles.*

Powered by Jotform SignClear
My child will attend church services when scheduled. *

Powered by Jotform SignClear
If offered the opportunity to partake in communion or water baptism participation is voluntary*

Powered by Jotform SignClear
If I object to the religious nature of this program and its requirements, I will notify the Center Director and receive a referral to another program of my choosing.*

Powered by Jotform SignClear
My signature below indicates that I have carefully considered the Christian nature of the program and have made a free and independent choice to participate in the Lakeside Academy program. I also acknowledge that I have been given the opportunity to ask for a referral list of other faith-based and secular programs.
I have spoken with my child about placing him/her in a faith-based program*

YesNo
Parent’s Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Parent’s Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Print Child’s Name:*

Full Disclosure to Minor

Lakeside Academy (LA) holds the position that full disclosure is the best method for placing a minor in our program. While most teenagers will not be happy about having to relocate to a new living situation, LA still requires a minimum awareness of the decision to be placed at LA. The minor should be informed in advance of the timeframe for placement, including the specific time and day for intake.
Additionally, the following items must be presented to the minor prior to intake:

 Lakeside Academy is Faith-based/Christian program  Program duration is a four level program up to twelve months  I acknowledge that if my child is discharged from the program, it is my responsibility to make sure that he leaves the facility within the time parameters set forth by Lakeside Academy Leadership.  I acknowledge that if my child runs from the campus the Wright County Sheriff’s Department is called and they will apprehend my son.  If my child has been involved in problematic behavior at the program setting or outside the program setting and/or breaks the law, he may be charged with a crime and face court consequences including incarceration, fines, probation, etc.
3rd Party Transportation Services

 Admission by a transport service is allowed on a case-by case basis  Although transport services can be expensive, this may be an option to bring your son to LA; however, the same full disclosure policy still applies  If a minor arrives via transport without a reasonable amount of compliance upon arrival, the parent/guardian will be responsible for making immediate arrangements for the minor to return home
I understand these expectations and herby acknowledge acceptance of these terms. I also acknowledge that if a minor arrives at LA without prior knowledge, LA retains the right to rescind acceptance into the program.
Parent/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Parent/Guardian Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Print Child’s Name:*

Parental Release of Liability Agreement
I/We, Type a label , parent(s), guardian(s), or conservator(s) of
First Name Last Name , a minor child, born on Date , hereby agree that he/she can enroll in Lakeside Academy (LA) and Minnesota Adult and Teen Challenge (MnTC), a therapeutic boarding school. I/We further agree that I/we relieve LA/MnTC, its staff, employees, students, and board members from
any responsibility or liability for any damages to him or his property during his residence at LA/MnTC or during any related travel and/or activities. I/We also agree to release, hold harmless, and relinquish all rights to pursue any cause of action whatsoever against LA/MnTC, its staff, employees, students, and board members if a
resident voluntarily leaves LA/MnTC or for any damages incurred during his residence. I further acknowledge that LA/MnTC is not a lock down facility and that in the event my child runs away from the facility, LA staff will contact Wright County Sherriff Department to report the minor child as a runaway. Lakeside Academy will make every reasonable effort to return a former clients property we reserve the right to dispose of the property after 30 days.
Parent/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Parent/Guardian Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Emergency Medical, Surgical, and Dental Permit

Lakeside Academy may provide emergency services anytime the parent(s), guardian(s), or emergency contact person(s) cannot be reached, when, in the opinion of the attending, duly qualified physician, said services are deemed necessary or advisable. I/we consent to the administration of whatever anesthetics are advisable or necessary and I/we agree to be solely responsible for payment of any and all medical or dental services obtained.
Parent/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Parent/Guardian Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
APPLICANT’S STATEMENT

By my signature below, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers, my child may be discharged from the Lakeside Academy program. Furthermore, I understand that Lakeside Academy is a Christian, faith-based program and that I have made a free and independent choice to enroll my child. I understand that other program options are available to me and I have had an opportunity to request a referral. I agree that that I will settle any and all previously asserted claims, disputes or controversies arising out of or relating to my application, participation in and discharge from the Lakeside Academy program with Lakeside Academy by final and binding arbitration in accordance with the applicable American Arbitration Association rules of arbitration in effect on the date that arbitration is requested by either me or Lakeside Academy. I agree that all administrative costs of arbitration shall be divided equally among the parties.
Please initial indicating that you have received, read, and agree to abide by the following documents:
Lakeside Academy Student Handbook*

Powered by Jotform SignClear
Parent/Guardian Signature:*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Parent/Guardian Signature:

Powered by Jotform SignClear
Date

MonthDayYear
Date

Program Costs: Enrollment, Tuition, Deposits, and Other Fees
Cost of Program

Standard tuition covers: room & board (breakfast, lunch, dinner, and snack daily), 24/7 direct care staff, academic support for online school (classroom teacher), daily vocational experience (i.e. woodshop, welding, automotive, etc.) on-site recreational activities, individual and group counseling sessions and other basic behavioral groups.
Damage Deposit: $500.00 (Please bring cash, check, or credit card on day of admission)

A damage deposit is required for all applicants at the time of admission. Money from thisdeposit will be used to repair or replace damaged property caused by the student.Parents/guardians are required to replace money used from the damage deposit so that a$500.00 deposit is maintained at all times. A minimum charge of $50 will be charged perincident. Upon discharge, the damage deposit minus any damage expenses will be refunded.
Personal Needs Money: $300.00 (Please bring cash, check or credit card on day of admission)

The client personal account in which the client’s parent places money in to, is not for them touse at their leisure. The account is used for incidentals, haircuts, sometimes rec events as well asreward center.
Initial*

Powered by Jotform SignClear
Initial

Powered by Jotform SignClear

Program Costs: Tuition, Deposits, and Other Fees (cont.)
Program Fee Philosophy

It is common for boarding school and treatment programs to exceed $150,000, LAKESIDE ACADEMY will strive to keep your total yearly (12 months) out of pocket expenses down so that they do not exceed the amount of your deposit. Even if the services provided to your child greatly exceed your deposit, LAKESIDE ACADEMY will work with your insurance company and will utilize scholarships, grants, other third-party payers, debt forgiveness, etc. to accomplish its commitment to cap your total out of pocket expenses.LAKESIDE ACADEMY offers a discount if you choose to pay the entire deposit at the time of your son’s admission. We do understand that this may not be a feasible option for your family so LAKESIDE ACADEMY offers a 12 month payment plan. The first payment will include the first month and a non-refundable deposit. This amount is due at the time of admission. The details of the program fees and payment plan will be discussed in more detail with LAKESIDE ACADEMY’S admission staff.
Cost of Program

LAKESIDE ACADEMY will have two (2) cost plans: (1) with insurance and (2) without insurance. Within each of these plans, families will be able to receive a discount for full payment at time of admissions or commit to making payments over 12 months.
Cost of program with insurance:

Payment is made in full receiving 5% discount Payment is made over 12 months $48,605
Cost of program without insurance:

Payment is made in full receiving 5% discount Payment is made over 12 months $63,600
Refund Policy

Any excess funds or deposit monies remaining in the client/student’s account will be refunded within 30 days of the child’s discharge from the program. The refunds are calculated based on the balance of unpaid services.
I have read the statements above regarding the financial obligations of enrolling my son at Lakeside Academy and agree to these terms.
Parent/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Parent/Guardian Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date

If you experience problems with the submit button below, please call (844) 768-8336 or reach out to us through our Contact Us page.
Should be Empty:

	Medication Name	Dosage	Reason
1.
2.
3.
4.
5.
6.

Lakeside Academy Application

Applicant's Information:

Applicant's Demographics:

Primary Parental/Guardian's Information:

Secondary Parental/Guardian's Information:

Applicant's Insurance Information:

If yes, please provide the following information:

Important Note:

In your own words, tell us why you want your child to come to Lakeside Academy and the main issues you believe your child needs to deal with while in the program pertaining to the following areas:

Strengths and Assets Inventory

Reviewed Medications

Medical Marijuana

Medications used Specifically for Weight Loss

Muscle Relaxants

Stimulant Medications

Performance Enhancing Steroids/Supplements, or Herbal Supplements

Essential Oils

Scheduled/Controlled pain relievers, unless pre-approved

Antabuse

Medication Assisted Treatment (MAT)

Sleep Aids

Important Note:

Physical Health

Important Note:

Special Needs:

Mental Health

Legal Issues

Emergency Contacts

Substance Use

Previous Treatment for Substance Abuse:

Residential Alcohol and Drug Treatment

Out-Patient Alcohol and Drug Treatment

Please submit copies of the following with this application:

School/Educational

Most Recent School Attended:

IN ACCORDANCE WITH REVISED FEDERAL AND STATE STATUTES, PERMISSION OF THE PARENT OR ADULT IS NO LONGER REQUIRED WHEN RECORDS ARE REQUESTED BY AUTHORIZED SCHOOL PERSONNEL

Voluntary Compliance with Faith Based Activities

Please read each item carefully and initial your acceptance to each program requirement.

Upon admittance to Lakeside Academy, I understand the following (please initial each line):

Full Disclosure to Minor

Additionally, the following items must be presented to the minor prior to intake:

3rd Party Transportation Services

I understand these expectations and herby acknowledge acceptance of these terms. I also acknowledge that if a minor arrives at LA without prior knowledge, LA retains the right to rescind acceptance into the program.

Parental Release of Liability Agreement

Emergency Medical, Surgical, and Dental Permit

APPLICANT’S STATEMENT

Please initial indicating that you have received, read, and agree to abide by the following documents:

Program Costs: Enrollment, Tuition, Deposits, and Other Fees

Cost of Program

Damage Deposit: $500.00 (Please bring cash, check, or credit card on day of admission)

Personal Needs Money: $300.00 (Please bring cash, check or credit card on day of admission)

Program Costs: Tuition, Deposits, and Other Fees (cont.)

Program Fee Philosophy

Cost of Program

Cost of program with insurance:

Cost of program without insurance:

Refund Policy

I have read the statements above regarding the financial obligations of enrolling my son at Lakeside Academy and agree to these terms.

If you experience problems with the submit button below, please call (844) 768-8336 or reach out to us through our Contact Us page.