2025-2026 Registration & Enrollment

2025-2026 Registration and Enrollment

Welcome to The Clear View School Day Treatment Center's electronic registration and enrollment process.

Please complete each page carefully and thoroughly. The information entered immediately below will auto-populate throughout the forms to simplify and streamline your process.

Please be sure to create a Jotform account (or log in to your existing account) if you'd like to save your answers and return to finish your child's forms later. Once you're signed into Jotform, you can click "save" at the bottom of any page, and you'll be emailed a link that will bring you back to where you left off.
Parent / Guardian Completing Registration
Your First Name*
Your Last Name*
PG's Full Name
Your Email Address*
Student
First Name*
Last Name*
Date of Birth*

MonthDayYear
Age Verification
Is 18+

YesNo
Today's Date

MonthDayYear
Today's Date Calculation
Student's Full Name

Registration Form

In registering my child, {StudentFull} , at The Clear View School Day Treatment Center, I hereby consent to their participation in the special education and mental health treatment services provided by this program.

I understand that the Association for Mentally Ill Children cannot be held responsible for any damages my child might cause to any person(s) or property while in the care of the Association and I further exonerate the Association completely from any responsibility for such damages.

I have received, read through and made myself familiar with the contents of The Clear View School Day Treatment Center’s Family Handbook.
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Medical Contacts

Please provide contact information for {StudentFirst}'s primary care physician. We may contact them directly to request necessary paperwork (i.e., annual physical) and in the event of an emergency.
Doctor's Name*
Practice Name*
If applicable
{doctorsName}'s Phone*
Placeholder
{doctorsName}'s Fax*
{doctorsName}'s Address*

Street Address

Suite/Unit/Fl.

CityState

Zip Code
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Medicaid and Insurance Information
Does {StudentFirst} receive Medicaid?*

YesNo
Does {StudentFirst} receive Medicaid? 2

YesNo
{StudentFirst}'s Medicaid Number
CIN, Program ID, Member ID, or ID
Please upload a copy or photo of {StudentFirst}'s Medicaid card below.

Cancelof
Does {StudentFirst} have a primary private insurance provider (not Medicaid)?*

YesNo
Does {StudentFirst} have a primary private insurance provider (not Medicaid)? 2

YesNo
Insurance Provider
Policy Number
{PPIN}'s Address

Street Address

Suite/Unit/Fl.

CityState

Zip Code
{PPIN}'s Phone
Placeholder
{PPIN}'s Fax
Please upload a copy or photo of {StudentFirst}'s private insurance card(s) below.

Cancelof
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Emergency Medical Treatment Release

In the event of an emergency, I hereby give permission to The Clear View School Day Treatment Center to obtain medical and surgical treatment of my child, {StudentFirst}.

I authorize transportation to a hospital, where required, and treatment by a physician or surgeon in the event that it should be deemed necessary. I agree to assume responsibility for all charges so incurred.
The following information should be available to an emergency physician (i.e., allergies, medication, etc.):
Insurance Provider
Policy / Medicaid Number
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Medication Permission
Please indicate below your consent for medication to be administered to {StudentFull} at Clear View.*

YesNo
Medication Permission Text
Yes - I give permission for medication to be administered to my child, {StudentFull}, at The Clear View School Day Treatment Center as prescribed and according to program policies.
No - I do not give permission for medication to be administered to my child, {StudentFull}, at The Clear View School Day Treatment Center. I agree to respond promptly to outreach from The Clear View School Day Treatment Center when my child or my child’s treatment team (including the nursing office) have a concern about how my child is feeling physically.
I give permission for medication to be administered to my child, {StudentFull}, at The Clear View School Day Treatment Center as prescribed and according to program policies.

YesNo
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Agreement to Share Psychopharmacological Information
Who prescribes {StudentFirst}'s medication?

Dr. HaagenAn outside prescriber
Who prescribes {StudentFirst}'s medication? 2

Dr. HaagenAn outside prescriber
I, {PG1Full}, understand and agree that direct access to my child's psychopharmacological medication provider, for sharing of information and necessary treatment collaboration, is required by The Clear View School Day Treatment Center.
Prescriber's Name
Practice Name
If applicable
{PSCN}'s Phone
Placeholder
{PSCN}'s Fax
{PSCN}'s Address

Street Address

Suite/Unit/Fl.

CityState

Zip Code
Dr. Haagen's Address
Dr. Haagen's City
Dr. Haagen's State
Dr. Haagen's Zip Code
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian

Clear

Immunization Policy

The Clear View School Day Treatment Center requires immunization records from all students prior to admission. We comply with yearly reporting requirements to the New York State Department of Health. All students are required to be immunized according to the most current New York State Department of Health schedules.

PHL 2164 and the regulations of the Commissioner of Health, 10NYCRR §66-1, define terms and immunization requirements for admission into Pre-K through 12 schools. A chart of current immunization requirements for school attendance is available here.
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Acknowledgement of Program Policies

I, {PG1Full}, parent/legal guardian of {StudentFull}, acknowledge that I have received notice of the following policies of The Clear View School Day Treatment Center, which are posted on The Clear View School Day Treatment Center’s website and are included in The Clear View School Day Treatment Center's Family Handbook:

• Children’s Internet Protection Act (CIPA) Policy

• The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule

• Notice of Parents’ Bill of Rights for Data Privacy and Security Under FERPA and NYS Education Law §2-D
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Funding for Education and Treatment Release

I hereby give permission to The Clear View School Day Treatment Center and The Association for Mentally Ill Children of Westchester, Inc. (AMIC) to obtain funding for any and all special education and/or treatment services provided for my child and family from all sources allowed by Federal or New York State Law and Regulation. I further consent to the release of any and all information required to obtain such funding.

This release includes, but is not limited to information and billing:

• To receive tuition funds from the State Department of Education, from my local Board of Education or from any other source of public function for educational purposes

• To receive payment from Medicaid or Medicaid insurance.

• To bill private medical insurance when necessary.
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Activity Permission

I hereby give permission for {StudentFull} to participate in any and all activities of The Clear View School Day Treatment Center program.

I give permission for my child to take trips (within three miles) or walks away from program grounds when the staff deems such trips or walks to be of benefit to my child.

I give permission for my child to take part in playground and other physical activities during the hours that they attend The Clear View School Day Treatment Center and generally to participate in all of the activities which the program involves, unless I have given specific, written instructions that such participation is not permitted.
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Field Trip Permisson

I hereby give permission to The Clear View School Day Treatment Center to take my child {StudentFull} on field trips away from program grounds where the staff deems such field trips to be of benefit to my child.

I understand that the purpose of field trips is basic education and/or enrichment and will generally include recreation and socialization activity. They may be planned or spontaneous. The duration of such field trips may be all or part of a program day. Transportation methods may include public transportation, school vehicles, staff cars and hired vehicles, depending on the nature of the trip.

I further understand that my child will generally bring home a field trip notice a few days before the trip and that I can revoke permission for any particular trip to which I object by giving specific, written instructions that such participation is not permitted.
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Consent for Telehealth Services

Telehealth services are live two-way audio and video electronic communications that provide a way for mental health services to occur outside of the physical site of The Clear View School Day Treatment Center. The Clear View School Day Treatment Center’s telehealth policies and procedures are available here.

• Telehealth services are completely voluntary, and this consent may be withdrawn at any time.

• Rules of HIPAA and FERPA that protect privacy and confidentiality apply to telehealth. The physical space for both hub and distant site participants will provide for audio and video privacy. All participants will identify themselves to each other at the beginning of each session.

• Audio or video recordings of any portion of audio or video telehealth sessions may not be made by hub or distant site participants.

• Where the individual receiving telehealth services is a minor, the individual and his/her parent/guardian will be given the opportunity to provide input regarding who will be in the room with the individual when telehealth services are provided.

• Interruptions and technical difficulties are a risk of telehealth services. If an audio or video telehealth connection drops during a session, previously established plans for reconnecting will be engaged.

• A telehealth session may be discontinued at any time by hub or distant site participant if it is assessed that the audio or video technology is not adequate for the situation.

• If there is any emergency during a telehealth session, the provider may call emergency services or the designated emergency contacts.

I, {PG1Full}, hereby give my informed consent for the use of telehealth in my child's care and understand all of the above.
Consent

Yes
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Early Dismissal Permission
Please indicate below your consent for {StudentFull} to be sent home in the event of an early dismissal.*

YesNo
Early Dismissal Permission Text
Yes - I hereby give permission for my child, {StudentFull}, to be sent home from The Clear View School Day Treatment Center in the event of an early dismissal, even if I am unable to be reached by phone.
No - I do not give permission for my child, {StudentFull}, to be sent home from The Clear View School Day Treatment Center in the event of an early dismissal, unless I have been reached by phone.

I understand that if I cannot be reached by phone, my child's emergency contacts will be called.

I further understand that if neither I nor my child's emergency contacts can be reached in a timely manner, my child will be sent home on regular transportation and that our school district's transportation company will have discretion about where they are brought.
I hereby give permission for my child, {StudentFull}, to be sent home from The Clear View School Day Treatment Center in the event of an early dismissal, even if I am unable to be reached by phone.*

YesNo
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Photograph Permission
Please indicate below your consent for The Association for Mentally Ill Children of Westchester, Inc. and The Clear View School Day Treatment Center, and their designated agents to take photographs of {StudentFull} and to use such photographs at their discretion.*

YesNo
Photograph Permission Text 1
Yes - I hereby give The Association for Mentally Ill Children of Westchester, Inc. and The Clear View School Day Treatment Center or their designated agents, permission to take photographs of {StudentFull} and to use such photographs at the discretion of the above-named association and program.
No - I do not give The Association for Mentally Ill Children of Westchester, Inc. and The Clear View School Day Treatment Center or their designated agents, permission to take photographs of {StudentFull} or to use such photographs at the discretion of the above-named association and program.
Please indicate below your consent for {StudentFull}’s image, artwork, voice, stage production, to be used for program purposes, and to be displayed within The Clear View School Day Treatment Center’s buildings and grounds with {StudentFull}'s name as the subject and/or creator of the image.*

YesNo
Photograph Permission Text 2
Yes - When photographs, videotaping, stage productions, art projects and the like are created and used within the program, I understand that my child’s image, artwork, voice, stage production, may be used for program purposes. These may be displayed within The Clear View School Day Treatment Center’s buildings and grounds with my child’s name as the subject and/or creator of the image.
No - When photographs, videotaping, stage productions, art projects and the like are created and used within the program, I request that my child’s image, artwork, voice, stage production, are not used for program purposes. I request that they are not displayed within The Clear View School Day Treatment Center’s buildings and grounds with my child’s name as the subject and/or creator of the image.
I hereby give The Association for Mentally Ill Children of Westchester, Inc. and The Clear View School Day Treatment Center or their designated agents, permission to take photographs of {StudentFull} and to use such photographs at the discretion of the above-named association and program.

YesNo
When photographs, videotaping, stage productions, art projects and the like are created and used within the program, I understand that my child’s image, artwork, voice, stage production, may be used for program purposes. These may be displayed within The Clear View School Day Treatment Center’s buildings and grounds with my child’s name as the subject and/or creator of the image.

YesNo
Notes/Specifications:
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian

Clear

Electronic Device Agreement

Please review this agreement with your child and, if it makes sense, have them sign as well.

We understand that The Clear View School Day Treatment Center cannot assume responsibility for the protection of personal property brought from home. Electronic devices, including cell phones, are attractive targets for theft and are easily broken. The undersigned acknowledge that there is a possibility that any electronic device brought to program may be damaged or stolen and agree that neither the staff nor the students nor the agency itself will be held responsible for damage or theft, either in program or on the bus to program. The undersigned further agree that the use of any electronic device in the classroom will be governed by the rules, restrictions and teachers’ directions of the particular classroom.
{StudentFirst} may bring the following devices to program. We understand that these devices will be covered by this agreement:

Cell phoneTablet/iPadCameraMP3 player/iPodLaptopSmart watchHandheld gaming device (i.e., Nintendo Switch)Other
Signature of Student

Clear
Signature of Parent/Guardian*

Clear

Sunscreen and Insect Repellent Permission

Outdoor activity is an integral part of The Clear View School Day Treatment Center program, with the possibility of exposure to sun and insects.

The program maintains availability of sunscreen and insect repellent to address possible sun and insect exposures. Please indicate and sign below your consent to the use of sunscreen and insect repellant for your child.
I hereby consent to the use of sunscreen (SPF 15 or above) for my child.*

YesNo
I hereby consent to the use of sunscreen (SPF 15 or above) for my child. 2

YesNo
I hereby consent to the use of insect repellent spray for my child.*

YesNo
I hereby consent to the use of insect repellent spray for my child. 2

YesNo
Signature of Student (age 18+)

Clear
Signature of Parent/Guardian*

Clear

Pesticide Application Notification

New York State Education Law now requires written notification to parents, guardians and staff members regarding the potential use of pesticide periodically throughout the school year.

The Clear View School Day Treatment Center is required to maintain a list of persons in parental relation, faculty and staff who wish to receive a 48-hour prior written notification of certain pesticide applications. The following pesticide applications are not subject to prior notification requirements:
- A school remains unoccupied for a continuous 72 hours following an application
- Anti-microbial products
- Nonvolatile rodenticides in tamper resistant bait stations in areas inaccessible to children
- Nonvolatile insecticidal baits in tamper resistant bait stations in areas inaccessible to children
- Silica gels and other nonvolatile ready-to-use pastes, foams or gels in areas inaccessible to children
- Boric acid and disodium octaborate tetrahydrate
- The application of EPA designated biopesticides
- The application of EPA designated exempt materials under 40CFR152.25
- The use of aerosol products with a directed spray in containers of 18 fluid ounces or less when used to protect individuals from an imminent threat from stinging and biting insects including venomous spiders, bees, wasps and hornets
In the event of an emergency application necessary to protect against imminent threat to human health, a good faith effort will be made to supply written notification to those on the 48-hour prior notification list.

Since The Clear View School Day Treatment Center is committed to an integrated pest management approach, which involves infrequent use of the least toxic pesticides possible, with application during time when school is closed, it is unlikely that we would use pesticides which fall under the 48-hour notification provisions of this law.

However, in the event that we must use such a pesticide at any time in the future, please fill out the form below. Please feel free to contact Nancy Collazo, Chief Operating Officer, for further information on these requirements.
I would like to receive 48-hour prior notification of pesticide applications that are scheduled to occur, as provided for in New York State Education Law.*

YesNo
I would like to receive 48-hour prior notification of pesticide applications that are scheduled to occur, as provided for in New York State Education Law. 2

YesNo
Please confirm that the information below is correct:
Your First Name
Your Last Name
PG's Full Name
Your Address

Street Address

Apt./Unit/Fl.

CityState

Zip Code
Your Mailing Address

Address

CityState

Zip Code
Cell Phone
Placeholder
Home Phone
Should be Empty: