LITTLE WOUND MIDDLE SCHOOL

In Case of an Emergency, Contact:

Medications:

If child needs to take long term prescription medication at school, all medication must be brought to the nurse's office by an adult, in original bottles with student's name on it.

Vaccinations:

School Policy states any student entering LWS shall, prior to admissioin, be required to present to the appropriate school authorities certification from a licensed physician that the child has received or is in the process of receiving adequate immunization against poliomyelitis, diphtheria, pertussis, rubeola, rubella, mumps, tetanus, meningitis, and varicella.

McKinney Vento Student Housing Form

Little Wound School may receive additionl money for the Bureau of Indian Education to provide services to our students depending on the living situations of our students.  Completing this form helps LWS apply for these resources.

All responses to the questions below are confidential.

If you have any questions regarding the McKinney-Vento Student Housing Form, reach out to the building principal.

Project AWARE / Strategic Prevention Framework

Informed Consent Form

Background: Little Wound School is implementing a comprehensive mental and behavioral health support system within our school to promote prevention of substance use, misuse, and abuse. Services offered will be based on a concept called the trauma-informed schools’ model, which understands that our school’s students may experience trauma (both historical and contemporary) in their lives and can be supported with cultural activities, counseling, and other targeted approaches. These approaches can help our students dealing with trauma succeed in both school and life and reduce their proclivity to use, or use of, alcohol, drugs, and other illicit substances. Our district believes that these services will be beneficial to our student community and we invite your student to participate in them. A student’s participation in this project will open the door to a number of opportunities for students, including: participation in additional cultural ceremonies and activities on campus; access to expanded student support services; and receive training about trauma and positive coping mechanisms.

Participation in these activities is voluntary. By completing this form and returning it to your student’s school, you agree that you have read through this informed consent document and that you and your student agree to participate in services related to the implementation of the school’s program funded by the Strategic Prevention Framework—Partnerships for Success for Communities, Local Governments, Universities, Colleges, and Tribes/Tribal Organizations (SPF) grant offered by the U.S. Department of Health and Human Services.

Opta Ocanku Alcohol/Drug Screening Consent Form

Little Wound School  through the LWS Opta Ocanku counseling program will be offering Counseling services for Students that may be affected by problems with  Trauma, Mental /Behavioral Health Issues  that keep them from fully engaging in their education.  It is important for you to know  the services we provide. 

Program Services   

Opta Ocanku Counseling Program’s standardized plan of services is to identify, screen, and refer students who are at risk for social, academic, emotional behavioral health or experiencing Substance Use issues and refer them to the appropriate treatment support services. Project staff will conduct initial screenings using the Semi-Structured Interview, Social, Academic, and Emotional Behavior Risk Screener, ACE’s survey, Personality Inventory for Youth, Substance Use screenings /Assessment, Beck Depression, Hopelessness and Anxiety screenings, based on these findings a proper referral will be determined and an individualized counseling plan will be developed, a range of evidence-based, trauma informed and cultural interventions such as cultural mentorship, Lakota Mental Health teachings, inipi, aziliya, cognitive behavioral therapy, internal family systems therapy, equine–assisted therapy, mindfulness/ meditation practices along with evidence based student counseling curriculums, which will be used in  individualized counseling, group counseling, outpatient services, treatment planning and continuum of care for students. 

We also provide training and education to community members on the signs of substance abuse disorders and distribute information on the effects of substance abuse and on how to refer individuals for substance use disorder.

I also understand that if my child is determined to need services beyond the scope of services provided by LWS  Opta Ocanku, that referrals to appropriate agencies will be made.  

I also understand that any services may be held during the regular school hours, but will have activities that may require them to ride the activities bus home.   

Patient Rights:  During your involvement with our program you have the following rights:

• The right to be informed regarding the nature of the treatment planned including benefits expected, risks involved, and participation in the development of the treatment plan.
• The right to refuse treatment
• The right to reserve confidentiality
• The right to be treated with full recognition of your personal dignity, individuality, and need for privacy
• The right to receive services in adequate facilities
• The right to know the qualifications of the staff providing your services.

 If you have questions please contact our staff at 605-455-1632.

Participate in School Related Activities

I give my consent for my son/daughter to participate in all school related activities.  The school personnel will do within their power to safeguard the health and well being of the student to participate in all school activities, but are not responsible for accidents beyond their control.  In case of any accident or illness while the student is participating or in route to participate in a school activity, I give my permission and signed consent to emergency medical care, including emergency dental or minor surgery, if such procedures become necessary, while the student is under jurisdiction of the Little Wound School.  

Records Release

I give the proper authorities/personnel of Little Wound School the authority to acquire all necessary documents from various departments and agencies that are required to attend Little Wound School.

Counseling Services

I agree to the standard and normal practice that students are able to see a counselor when it becomes necessary for Little Wound School to provide any counseling session deemed necessary for my son/daughter.

Photo Release

All photographers taking photographs on school property or of school events or students work must obtain a signed release form from any student or staff member who is visibly recognizable in the photograph.  Crowd scenes where no single person is the dominant feature are exempt.  

These rules governs photographs intended for use in any school publication of marketing or a public relations nature, such as newsletters, brochures, yearbooks, promotional items, or other such material, including photographs used on the web.  These rules are not in effect when photographs are taken of news events, but photographs taken for news purposes requires a release for reuse in marketing materials.

Internet User Agreement

I grant permission for my son or daughter to access networked computer services such as electronic mail on the Internet. I understand that individuals and families may be held liable for violations. I accept full responsibility for child’s use of the Internet and technology equipment that may be issued to the child.

School-Parent Compact

Little Wound School, and the parents of the students participating in activities, services, and programs funded by Title I, Part A of the Elementary and Secondary Education Act (ESEA) (participating children), agree that this compact outlines how the parents, the entire school staff , and the students will share the responsibility for improved student academic achievement and the means by which the school and parents will build and develop a partnership that will help children achieve the State’s high standards. Working together, teachers, parents, and students will form a partnership to help each child achieve success in school. Our united effort will benefit your child by supporting their success in school.

ATTACHMENTS

Please Read the following statement:

Documents required for registration for new students include: Birth Certificate, Immunization Record, Tribal Enrollment, Custody Document, Test Scores. If you have any of these documents in an electronic format, please upload the document(s) below. Please bring to the school secretary if you are not able to upload in this online format. This registration is only complete when these documents are submitted. It is also at the discretion of the school administrator to accept the registration of this student. The guardian will be notified in writing if the student cannot enroll at Little Wound School.

It is very important to sign this registration. Without a signature your child will not be enrolled until a valid signature is received.  By submitting this registration form, you are assuring Little Wound School that you are the legal parent/guardian of the student and all responses to this registration are accurate.