Autism Career Connection Registration

Autism Career Connection - Parent Student Handbook Acknowledgement
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General Contact Information
Student Name: *

First Name Last Name
Birth Date *

Month Day Year
Student Address: *

Street Address

Street Address Line 2

City State

Zip Code
Legal Guardianship: *

Both Parents Mother Father
Student/Guardian Signature* *

*If guardianship is restricted, you must supply legal documentation. Clear
If guardianship is restricted, please upload legal documentation here

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Parent/Guardian Information:
Is the Student their own Guardian? *

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

First Name Last 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

City State

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

Area Code Phone Number
Alt. Number

Area Code Phone Number

Master Other Contact

First Name Last Name
Master Other Work Phone

Area Code Phone Number
Master Other Cell Phone

Area Code Phone 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 student 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 student from school. Please notify your student's classroom teacher in advance when your student 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 student. Please indicate at least two individuals that are able to pick up your student other than the parent/guardian.
Emergency Contact #1:
Is Emergency Contact the same as Parent/Guardian? *

No Yes
Name *

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

Street Address

Street Address Line 2

City State

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

Area Code Phone Number
Alt. Number *

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

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

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

Street Address

Street Address Line 2

City State

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

Area Code Phone Number
Alt. Number *

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

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

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

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Alt. Number

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

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 Code Phone Number
Physician Fax Number *

Area Code Phone Number
Student/Guardian Signature *

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Date *

Month Day Year

Authorization for Administration of Medication
Please complete our Authorization of Administration of Medication form for medications, including prescription and over-the-counter (i.e., Tylenol, cough medicine, allergy, Neosporin, etc.), to be taken by your student during school hours. All medication must be dropped off at school in the original prescription container appropriately labeled by the pharmacy. If it is over-the-counter medication, it needs to be dropped off in the original package with your student’s name on it. Parents must provide written authorization by the physician with diagnosis and specific directions for dispensing of medication. Authorization forms must also be signed by the parent/guardian.

*Forms must be renewed each school year, each medication to be administered at school must have a separate completed form, any incomplete forms will be returned and authorization will not be honored until they are complete with the necessary details.

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 student's medication status: *

Yes, my student is taking medication No, my student is NOT taking any medication

Community-Based Instruction, Field Trip and Transportation Forms
Please sign and date the enclosed form granting permission for Turning Pointe employees and agents to provide transportation for the student for community outings, field trips, and participation in Turning Pointe’s programs. 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.
As part of the Turning Pointe Autism Foundation Adult Services curriculum, individualized programs will be organizing certain field trips in the community, to corporate partners and other work environments. If you have any questions about these activities please contact the instructor.
Please Choose One of the Following: *

Yes, I DO give consent for Turning Pointe Adult Services staff to transport the student for community outings and field trips. No, I DO NOT give consent for Turning Pointe Adult Services staff to transport the student for community outings and field trips.
Student/Guardian Printed Name *
Student/Guardian Signature *

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Crisis Management Notification
Turning Pointe Adult Services utilizes Professional Crisis Management (PCM) procedures, isolated time-outs, calm rooms, and safety equipment to maintain safety. You will be contacted if an isolated time-out or PCM procedure is utilized for the student; please indicate on this form how you would prefer to be contacted. Additionally, sign this form to indicate that you have received notification of Turning Pointe’s use of crisis management systems.
In the event of an isolated time-out and/or PCM procedure for my student, I would like to be contacted by (indicate preference): *

Email Phone
Email
example@example.com
Phone Number

Area Code Phone Number
Student/Guardian Signature *

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Media Release
Please complete this form to indicate your permission for Turning Pointe Adult Services and/or Turning Pointe Autism Foundation to use media (i.e. photographs, video, work etc.) of the student 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 No
I DO give a media release for my student {studentName}, to be photographed and/or videotaped for educational and public relations purposes. I give permission for my student's photographs, pictures, work, and/or videos to be used on the Turning Pointe website, brochures, advertisements, newsletters, and/or other media-based outlets.
Please list any restrictions to the media release you would like implemented for your student:
I DO NOT give a media release for my student, {studentName}, to be photographed and/or videotaped for educational and public relations purposes. I DO NOT give permission for my student's photographs, pictures, work, and/or videos to be used on the Turning Pointe website, brochures, advertisements, newsletters, and/or other media-based outlets.
Student/Guardian Signature *

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Health and Communicable Disease
Student Name: *

First Name Last Name
HEALTH

School attendance is important; however, your student may need to stay home because he/she is too sick to effectively learn at school and/or he/she 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 students home OR students 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, he/she will be sent home:
- Fever
- Vomiting
- Persistent diarrhea
- Rash associated with fever
- Sore throat
- Mouth sores
- Eye infections (conjunctivitis or pink eye)
- Difficulty breathing
- Drastic change in baseline behavior
In the event that your student displays any of the above symptoms, please keep them home from school. Thank you for your assistance.

***Students may return to school once they are symptom-free for 24 hours. Absences due to illness that last 3 or more days, need a release from a physician to return to school.***

COMMUNICABLE DISEASES
Please report to the school any communicable diseases including strep throat, chicken pox, mumps, pertussis, measles, impetigo, conjunctivitis, and head lice, as soon as the diagnosis is complete. Notice of potential exposure to these diseases will be sent home when the first case appears in the school. Please be assured that your student’s name will not be released on the notice.
Student/Guardian Signature: *

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School and Home Agreement
Please review and sign the agreement between school and home. A fully executed copy will be provided to you.

To facilitate constant, honest and respectful communication between the Adult Services and Parents/Families, the following agreement outlines the responsibilities in improving student outcomes.

Turning Pointe Adult Services Promises to:
- Offer evidence-based practice in all educational capacities during school day activities, lessons, community outings, and behavior management
- Collaborate with the student's entire team including progress on goals and program outcomes, school updates, twice-annual parent conferences, and regular emails
- Utilize best-practice in the areas of assessment, teaching methodologies, behavior interventions, and overall school-wide programming
- Communicate to districts, families, employers, and job sites on a regular basis, including progress on goals and program outcomes, school updates, twice-annual parent conferences, and regular emails.
- Recruit & train highly qualified specialists and staff as well as offer robust training opportunities for staff
- Respect parent's suggestions on student observations appreciating they know their student best
- Trust parent feedback and observations
Parents/Guardians Promise to:
- Remain connected to adult services via semester updates, with an emphasis on sharing any life, routine or medical changes for the student, and by reading information disseminated by the Adult Program
- Attend parent meetings and training
- Attend program meetings
- 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 student illness policy
- Respect Turning Pointe's team member as professionals fully vested in your student's success
- Trust Turning Pointe assessments and recommendations appreciating their expertise in the field
- Establish and continue routines to support your students' learning including pre-employment routines (i.e hygiene, meal preparation, housework)
Remember that administration specialists and staff may have different assessment results and intervention plans based on a student in the school environment. As an open mind and appreciation that opinions 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 Administrator Signature
Student/Guardian Signature *

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Peanut and Tree Nut Free Building
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.
Student's Name *

First Name Last Name
Parent/Guardian Name *

First Name Last Name
Student/Guardian Signature *

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Name/Organization:	Turning Pointe Autism Foundation - CN Day School
Address:	1500 W. Ogden Avenue
City:	Naperville
State:	Illinois
Zip Code:	60540
Phone:	630-570-7948
Fax:	630-615-6050