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    Mission Statement

    Keystone Achievements will embrace all families with compassion and provide the highest quality services for our families. All employees will communicate with students and their families with the greatest respect and care for the challenges these families face. Keystone Achievements is dedicated to creating a work environment that provides opportunities for its employees through career growth, learning, safety, and transparent appreciation of the entire team and families we serve.

    “Change takes commitment from us all. Understanding ABA and connecting the practice to all environments of a child’s life are key to progress and independence.”

    — Keystone Achievements

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    Please Note: It is very important that ALL the information requested in this packet is filled out and completed with signatures. This information is required for licensing and insurance. Should Keystone need to contact you for missing information, it will delay your child’s intake and insurance processing. The entire packet is to be returned upon completion. Should you have any questions, please contact Keystone for clarification before turning in the packet.

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    • Saudi Arabia
    • Senegal
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    • Spain
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    • Sweden
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    • Syria
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    • Tajikistan
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    • Thailand
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    • Togo
    • Tokelau
    • Tonga
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    • Trinidad and Tobago
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    • Tunisia
    • Turkey
    • Turkmenistan
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    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
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    • Minimum
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    NOTE: Any changes in medication must be communicated to Keystone Achievement staff as soon as possible.

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    Please answer the questions below for the problem behavior that you feel is most dangerous.

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    Please answer the questions below for the problem behavior that you feel interferes the most with day-to-day activities (if different than above).

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    Please answer the questions below for the other problem behavior you just identified.

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    Keystone Achievements is regulated by the State of Colorado, which requires all students attending licensed facilities to be vaccinated unless there is an exemption on file with the state. The immunization law was created in 2019 to support overall health of individuals and combat preventable diseases. The state has created a CIIS portal for providers to access student immunization records for all enrolled students.

    In the event Keystone is unable to pull the immunization records, we will attempt to request this from the primary care physician. After 2 records request the parents will be required to provide the immunization form.

    If your child has an exemption whether it be medical or religious, it must be filed with the state. On an annual basis Keystone Achievements is required to have the families with an exemption complete training on the CIIS portal. The immunization certificate will be valid through June 30th and must be saved by the family. After the certificate is saved, make sure to provide a copy to Keystone Achievements.

    https://www.dcphrapps.dphe.state.co.us/storyline360/story.html

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    I, *     *    , parent/guardian of    *     * attest that my child is in good health.

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    I, *     *    , parent/guardian of    *     * ask that Keystone Achievements leadership provide medication according to the Health Care Provider's signed instructions.

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    Parents/guardians MUST supply any of the medications that may be administered to your child. All medications to include PRN over the counter medications must have a written consent to be administered by Keystone Achievements.

    All medication must be picked up by the parent at the discharge of ABA services. All medications that are left at the school will be discarded according to state regulatory recommendations for safe medications disposal.

    Medications must come in a labeled container with the child’s name, medicine, time medicine is to be administered and licensed providers information.

    Over the counter medication must be labeled with the child’s name and packaged within the original container following the provider’s instructions.

    By signing this document, I give permission for the child’s health care providers to share information about administration of this medication with the Keystone Leadership team to administer medication.

    I understand that Keystone Achievements does not have licensed medical personnel on staff and medications will be administered by an individual with a QMAP Certification.

    In consideration and acceptance of this request to perform this service by personnel employed by Keystone Achievements, I hereby agree to release Keystone Achievements and its personnel from all liability, claims or demands for any damage, loss or injury to my child arising out of administration or failure to administer medications.

    Click to download Physician Medical Consent form.

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    • Other family
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    1. Consent for Treatment: I consent to telehealth care (i.e., live videoconferencing, face-to-face interactions) performed by my BCBA or other provider of the same degree level. This includes parent training and direct care modification if medical necessity criteria are met. I also understand that at any point in time I can refuse the telehealth services in which my regular in-person treatments will not be affected.

    2. Consent for Telehealth Services: Telehealth involves transmission of video and details of medical records also known as data. All Data is sent by a secure electronic means to facilitate the medical services being performed.

      • I will be informed of any other people who are present at either end of the telehealth encounter and have the right to exclude anyone from either location.

      • All confidentiality protections required by law or regulation will apply to my care.

      • I have the right to refuse or stop participation in telehealth services at any time and request alternate services such as an in-person appointment.

      • The members shall have access to all medical information resulting from the telemedicine services as provided by applicable law for member access to his or her medical records.

      • The services must be HIPAA compliant with sufficient audio and visual fidelity and clarity as to be functionally equivalent to live video conferencing, face-to-face contact. Telehealth services do not include telephone conversations or internet-based communication between providers or between providers and members.

      • If an emergency occurs during a telehealth encounter at a hospital or clinic, health care personnel at my location will manage the emergency. If an emergency occurs during a telehealth encounter when I am at anon-health-care site, I should call 911 and stay on the video connection (if applicable) until help arrives.

    3. Mandatory Reporting: Keystone employees are mandatory reporters of child abuse under Colorado’s Mandatory Child Abuse Reporting Law. If an employee has reasonable cause or suspects that a child is subject to circumstances or conditions which would reasonably result in abuse or neglect, they are required to report this information to Colorado Department of Human Services.

    4. Guardians present: If you choose to participate in telehealth sessions, parents must be available during entire telehealth visit may be asked to participate in parent meetings, implementing programming directly, or observing sessions. Likewise, parents may also be asked to step out of line
      of sight while remaining present if necessary.

    By signing this form, I acknowledge that I have read this information and agree to treatment by telehealth.

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    In case of accident, illness, or another emergency, I request that Keystone contact me. If Keystone cannot reach a parent or guardian after conscientious effort, I give permission for Keystone staff to call paramedics or any licensed physician or dentist. If a life-threatening emergency exists, I give permission for Keystone staff to call paramedics immediately and then contact me as soon as possible thereafter.

    I authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which, in the best judgment of a licensed physician or dentist is deemed advisable. I agree to assume financial responsibility for expenses incurred as a result of those services being provided. I agree to be financially responsible for emergency medical transportation.

    I understand it is my responsibility to update the Emergency Contact Form Keystone keeps on file with any changes as soon as possible in case of an emergency.

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    From the Safety Care by QBS, Inc. web page (qbs.com/safety-care):


    “Safety-Care® Behavioral Safety Training program provides the skills and competencies necessary to effectively prevent, minimize, and manage behavioral challenges with dignity, safety, and the possibility of change. Safety-Care provides the tools you need to be safe when working with behaviorally challenging
    individuals. Using up-to-date and effective technologies from Applied Behavior Analysis (ABA) and Positive Behavior Interventions & Supports (PBIS)… These strategies are appropriate for individuals experiencing developmental, neurologic, psychiatric, and other impairments. Safety-Care promotes a positive reinforcement-based approach and develops new skills, resulting in fewer restraints.”

    Before restraints are used the following criteria must be met and are continuously reviewed as the hold progresses to ensure they are still being met and a hold is still necessary.

    1. There must be imminent risk of serious harm to the agitated individual or someone else.

    2. There must be no other practical way to prevent that harm without physical management.

    3. The risk of not intervening must be greater than the risk of intervening.

    As a part of our process, we actively seek alternatives to physical management and methods of increasing the safety of a situation to either end a hold sooner or prevent the need for one at all.

    A restraint is any intervention that restricts a person’s movement. Safety care only uses physical restraints in the form of people holding people. No mechanical or chemical restraints are used. Safety Care’s physical restraints focus on keeping students in neutral and comfortable positions throughout the duration of the hold
    to reduce likelihood of injury or further agitation. If a restraint is used, a physical assistance report is required detailing the circumstances in which a copy will be provided to the parent/guardian.

    If you would like additional information or a more in-depth explanation of Keystone Achievement’s implementation of Safety Care, please call or email Keystone requesting to speak with your Center Director or a Safety Care trainer. Someone will reach out to you as quickly as possible.

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    I, *     *    , parent/guardian of    *     * consent that Keystone Achievements will utilize physical management when my child meets the criteria above. After the incident the leadership team will follow up with a written document for the family’s records.

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    I,      as a parent or guardian, give my consent for Keystone
    Achievements to provide behavior analytic services to my child        , in accordance with the ethical guidelines proposed by the Behavior Analyst Certification Board (BACB). I also understand that I may withdraw my consent and terminate treatment at any time and for any reason.

    I understand that any information provided in this intake as well as any information obtained at any point during the interview process or course of treatment, is kept strictly confidential in accordance with HIPAA regulation guidelines and the law. I understand that state laws may require that confidentiality be broken under certain circumstances, specifically, if I am judged by the behavior analyst to be of danger to myself and/or others, gravely disabled, or if there is suspected child abuse.

    I understand that Board Certified Behavior Analysts are bound to strict ethical guidelines of practice and that any issues of concern that may arise throughout the treatment process that are out of the behavior analyst’s area of experience may result in referrals to a more appropriate agency or individual.   

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    Keystone Achievements strives to provide the highest quality ABA services for our families. Achieving this goal requires the commitment of both Keystone’s team and each family we serve. Consistent attendance, on-time arrival, and on-time pick-up are keys to success each day for your child and an efficiently operating center. Keystone has exacting standards for each therapist to be prepared ahead of time for their sessions with both in center and in-home with the same requirements of the therapist for on-time arrival.

    Cancellations and Punctuality
    Absences due to appointments and vacation are anticipated events you can inform Keystone of in advance. Notifying Keystone of cancellations due to illness, car issues, or family emergencies should be given with as much advance notice as possible, as it is critical for planning each day. Similarly, we understand that life happens and there will be times when you are late. Your understanding of the importance of timeliness and your efforts to ensure punctual drop-off and pick-up makes a tremendous difference to the day running efficiently for all of us. Consistency in ABA is vital to your child’s success.

    Families are permitted three (3) cancellations per month. Any change in the schedule is considered a cancellation.

    • Absences due to illness and vacation that extend more than one consecutive day is considered one cancellation.

    • More than 15 minutes late for drop-off is considered a cancellation. Keystone may reassign the therapist and cancel the entire session if not notified of the late arrival ahead of the scheduled start time.

    • More than 5 minutes late for pick-up is considered a cancellation, as this is a change in schedule we are not prepared to accommodate, particularly at the end of the business day.

    • If there are more than three (3) cancellations in a month, someone from Keystone will contact the family to review the attendance policy and discuss solutions.
       
    • If more than three (3) cancellations occur per month in two (2) consecutive months, Keystone will review the circumstances and determine if services will continue under agreed upon conditions with the family or discharge to allow families on the waitlist to start services.
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    Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

    The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

    The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

    You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for
    the use of the information for treatment, payment, or healthcare operations.

    By signing this form, you consent to our use and disclosure of your protected healthcare information. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.


    By signing this form, I understand that:

    • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

    • The practice reserves the right to change the privacy policy as allowed by law.

    • The practice has the right to restrict the use of the information.

    • The patient has the right to revoke this consent in writing at any time and all full disclosures will then
      cease.
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    Program Description

    When opted-in, you will receive text messages (SMS/MMS) to your mobile number. This type of message may include a response to an inquiry, real-time texts to ask and answer questions about our services and pricing, and appointment confirmations.

    Program Frequency
    Message frequency will vary depending on the conversation.

    Opt Out

    You can opt out of this service at any time. Just text “STOP” to the phone number. After you text “STOP” to us, we will send you an SMS reply to confirm that you have been unsubscribed. After this, you will no longer receive SMS messages from us.

    If you want to join again, just sign up as you did the first time or text “START,” and we will start sending SMS messages to you again.

    Help
    If you are experiencing any issues, you can reply with the keyword HELP. Or you can get help directly from us at helpsupport@keystoneacheve.com.

    Interruption
    Keystone Achievements’ electronic transmissions through any carrier are not guaranteed. Carriers, such as the following, but not limited to: AT&T, T-Mobile, Verizon, Cricket, etc. are the party liable for delayed or undelivered messages. 

    Costs
    Message and data rates may apply for any messages sent to you from us and to us from you. If you have any questions about your text plan or data plan, please contact your wireless provider. 

    Privacy
    If you have any questions regarding privacy, Keystone’s privacy policy will be provided upon request. It is also available on Keystone Achievements’ website at www.keystoneachievements.com/privacy-policy.

    Keystone Achievements utilizes email to text messaging for enhanced communication with our parents. This system is used for notifications for scheduling issues such as session delays, center closures, weather related issues, etc.

    Keystone is a HIPAA compliant company, and it is important for us to protect your Private Health Information (PHI). 

    Text messages are not HIPAA compliant, therefore, Keystone Achievements will never send any PI or confidential notifications through this system. 

    In accordance with our privacy policy, Keystone Achievements does not share this information with any other entities and does not use this service for marketing purposes. Message and data rates may apply for this service through your carrier.
    By signing this form, you agree to receive text messages from Keystone Achievements. You may opt out of this service anytime by replying STOP to any text message.

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    I,      hereby authorize Keystone Achievements and the
    person/organization(s) listed below to release and exchange psychological, educational, medical, and other information about:

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    I understand that this authorization is valid for the period in which my child is an active Student with Keystone Achievements. I understand that I may see the information that is to be sent, and that I may revoke the authorization at any time by written, dated communication.

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    Please Select
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    • Parent
    • Guardian
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    All information relating to a student’s care, treatment, or condition constitutes confidential information. This confidentiality policy is to ensure all Student’s rights are upheld and respected by employees, Keystone Achievement families and their associates, contractors, and volunteers.

    • Confidential matters involving Students will not be discussed in areas where families or other non-employees of Keystone Achievements might overhear them. Staff members, families, and visitors are to always be aware that conversations regarding Students are not to be overheard by others and take appropriate steps to ensure this confidentiality.

    • All correspondence, reports, and billing records will be kept in strict confidence and only released according to HIPAA guidelines.

    • Any unauthorized disclosure of confidential information by employees, families and their associates, contractors, or volunteers will be regarded as misconduct and may result in termination of employment, discharge from services, or no longer allowed on Keystone Achievement premises.

    I have read this policy and agree to the terms and conditions:

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    Secondary insurance

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    I, *     *  agree to pay Keystone Achievements for all services rendered and agree to abide by the following guidelines:

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    1. Funding Sources:

      1. Insurance: A prior authorization will be obtained for all insurance funded plans covering ABA services. Insurance agencies will be billed directly. I understand I am responsible for all co-payment amounts, co-insurance, and deductibles if part of my insurance plan. Co-pays and co-insurance will be collected monthly prior to services. Deductibles will be invoiced monthly after the insurance agency provides an Explanation of Benefits (EOB) showing the amount applied to the deductible. Invoice terms are due upon receipt.

      2. Private Pay: I agree to pay monthly services prior to services being rendered. Check or credit card payments are due on the first of each month. Monthly tuition for center services is $4,000 half-day and $8,000 full day. In-home services are expected to be a minimum of 50 hours per month. The rate will be based on the number of hours expected per week and billed at the agreed amount. Missed days will not be refunded.

    2. Credit Card Payment: You may keep a credit card on file for all out-of-pocket charges. A pre-authorized Use of Credit Card form must be completed and submitted.

    3. Nonpayment: If my account is over 30 days past due, I will receive a letter stating that I have 10 days to pay my account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and services discontinued.

    4. Insurance Copays and Deductibles: These will be billed to you after receipt of insurance payment for services.

    5. Returned check/insufficient funds: I understand I will be charged a fee of $35 for any returned checks.

    6. Cancelled Cancellation: If you fail to cancel a scheduled appointment within the cancellation guidelines you will be charged $100. This is not billable to insurance.

      1. 24-hour notice: I must provide 24 hours’ notice to Keystone Achievements in order to cancel center or home sessions or I will be billed for the session.

      2. In the event of an unexpected illness in which 24 hours’ notice cannot be made, I am required to provide at least a 2 hours’ notice prior to the start of a scheduled appointment in order to prevent being billed for the session.

      3. I understand that when a Student arrives late to a scheduled appointment, the Student is billed the rate of the full appointment. Repeated failures to attend scheduled sessions or frequently arriving late to scheduled sessions may result in termination of services.

    I have read and understand the payment policy:

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    I, Parent/Guardian of (child’s name) *     * , hereby grant permission to Keystone Achievements (Keystone) and its assignees and licensees to take photographs or videos of the above named minor child or dependent adult, and to make recordings of the above named minor child’s or dependent adult’s voice as indicated below:

    (Please check one choice in the box.) 

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    I give unrestricted permission for images, videos, and recordings of my child or dependent to be used in print, video, digital and internet media. I agree that these images and/or voice recordings may be used for a variety of purposes and these images may be used without further notifying me. I understand that the child’s or dependent’s name will not be used in conjunction with any video or digital images.
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    Keystone may use images, videos, and recordings of my child or dependent for educational purposes only, not marketing. For example, using a video of your child’s therapy session for Behavior Analysts to review for continuous development of your child’s program and review with your child and/or parent/guardian for educational purposes.
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    Keystone may use images, videos, and recordings of my child or dependent within the center only, not in the larger community. For example, posting your child’s image on bulletin boards within the center.
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    Keystone may use images of my child or dependent as part of printed materials only, no digital, video, or internet use. For example, using your child’s image in a brochure.
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    Keystone may use images, videos, and recordings of my child or dependent for educational purposes only, not marketing. This could be within the larger community. For example, using a video of your child in therapist training.
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    By GRANTING permission as directed above, I am giving the Keystone permission to use these images, videos, and recordings, as well as the above-named minor child’s or dependent adult’s likeness and voice within the bound of those directives, as follows:

    • The use may include reproduction, distribution, derivative works, display, and performance, both private and public.

    • The use may be in composite or modified forms and in any media, now known or later developed, including without limitation newspapers, television, radio, the internet, and social media.

    • The use may be for any purpose throughout the world and in perpetuity, including, without limitation, education, trade, advertising, and promotion.


    I further acknowledge that I will not be compensated for these uses, and that Keystone exclusively owns all rights to the images, videos, and recordings, and to any derivative works created from them.

    I waive the right to inspect or approve the use of any printed or electronic copy. I hereby release Keystone and its assignees and licensees from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright.

    This Release is binding on me, my heirs, assignees, and estate. Keystone is not obligated to use any of the rights granted under this Release.

    This Release expresses the complete understanding of the parties.

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    I,    *     *    , parent/guardian of  *     *    

        *    

    consent for my child to be evacuated or participate in Keystone field trips and outings specific to my child’s programs.

    Although Keystone is dedicated to providing a safe and enjoyable time for all students, accidents can still happen. I, the parent/guardian, understand that there are risks involved with participation in off-site trips and their associated activities. In consideration of my child being allowed to participate in this event, I assume responsibility for those ordinary and reasonable risks associated with the travel and activities.

    In the event the children need to be evacuated from the building due to a fire, unforeseen circumstances necessitating evacuation, or natural emergency, I understand my child may need to be transported away from the building for safety purposes. I assume responsibility for reasonable risks associated with travel.

    I agree to hold harmless Keystone Achievements, its affiliate organizations, employees, agents, and representatives, including volunteers and other drivers, from any and all claims arising from my child’s participation.

    This release agreement does not apply to claims of intentional (criminal) misconduct or gross negligence by Keystone Achievements, its employees, or volunteers. If such circumstances are proved in a court of law, I acknowledge and agree that Keystone achievements can assume no financial liability beyond its actual liability insurance policy in force.

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    I understand that I have the option to revoke or alter permission for my child to participate in the Keystone Store at any time.

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    Engaging in peer and community socialization in a safe and responsible way is part of every student’s plan in some respect. Keystone provides safe and positive outside activities for all students.


    We are asking for your consent to allow your student to participate in one or more of the outside activities listed below.

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    I,    *     (parent/guardian) of    *     * (child), give permission to Keystone Achievements staff members to apply sunscreen before going outside, and after every hour of original application for direct sunlight exposure for 10 minutes or longer.

    Please send your preferred sunscreen to your student’s center. It will be labeled and used only for your student. Keystone strongly encourages extra covering to be provided for your children such as hats, sunglasses, SPF clothing and any other sun coverings to provide a layer of support to the face, ears, scalp, and neck.

    Keystone requires families to supply sunscreen of their choice to prevent possible reactions by other brands known to the family. With written approval from the parent/guardian, should your student run out of their own sunscreen, Keystone Achievements will use Coppertone Pure Simple Kids SPF 50 Sunscreen spray for our students.   

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