SCHOOL-AGE APPLICATION

SCHOOL-AGE APPLICATION
___ AFTER SCHOOL ___ SOCIAL EVENTS ___ RESPITE ___ THERAPY
___ Initial I understand that there is a $15 registration fee due upon delivery of paperwork
GENERAL INFORMATION
Name: _____________________________________________________________________________
(Last)
(First)
(Middle Initial)
Parent/Guardian: ____________________________________________________________________
(Last)
(First)
(Middle Initial)
Date of Birth: _____/_______/_______ Age: ________ Gender: __Male __ Female
Address: ______________________________________________________________________________________
(Number and Street)
(City)
(Zip)
Phone Number: ________________________________________________________________________________
(Home) (May we leave message: _Yes _No)
(Cell) (May we leave message: _Yes _No)
Email: _____________________________________________________________________________
(May we email: _Yes _No) *Email correspondence is not considered to be a confidential medium of communication
Current School Attending: ______________________________________________________Grade:_____________
PARENT/GUARDIAN
Mother Name: ___________________________________ Mother Cell Phone: __________________________
Mother Employer:________________________________ Mother Work Phone: ________________________
Mother Home Phone:______________________________ Mother Email: ______________________________
Father Name: ____________________________________ Father Cell Phone: __________________________
Father Employer:_________________________________ Father Work Phone: _________________________
Father Home Phone:______________________________ Father Email: _______________________________
Household Residents – Relationship – Age:_______________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
AUTHORIZATION TO PICK UP PARTICIPANT
Mother: ____Yes ____No Father: ____Yes ____No -If NO to either parent, legal documentation must be provided.
Other- Name: ____________________________Relationship: ________________ Phone: ________________
Other- Name: ____________________________Relationship: ________________ Phone: ________________
___ Initial
If changes need to be made in future, please email information to OCA at [email protected]
Current Medication- Dosage- Times: ____________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___ Initial If medication is to be given at OCA, a Permission to Administer Medication form must be filled out.
.
Dietary Issues:_______________________________________________________________________________________________
Referred by (if any):__________________________________________
Has participant previously received any type of mental health services (psychotherapy, psychiatric services, etc.)
____No____Yes, previous therapist/practitioner: _________________________________________________
Medical Diagnosis/Concerns: __________________________________________________________________
__________________________________________________________________________________________
Are there sensory concerns (hearing, vision, tolerance)? _No _Yes, Please list ___________________________
__________________________________________________________________________________________
Are there ambulation concerns (assistive equipment, unsteady gate)? _No _ Yes, Please list _______________
__________________________________________________________________________________________
Have the participant ever been prescribed psychiatric medication? _No _Yes, Please list __________________
__________________________________________________________________________________________
History of psychosocial stressors: In this section, identify if there is a history of any of the following (these are applicable
to any member of the household).
Please Circle Appropriate Answer:
Alcohol/Substance Abuse: YES/NO
Physical Abuse: YES/NO
Eating Disorders: YES/NO
Suicide Attempts: YES/NO
Unemployment: YES/NO
Multiple Moves: YES/NO
Legal/DCF involvement: YES/NO
Peer Rejection: YES/NO
Abilities:
Can cut food YES / NO
Can use microwave YES / NO
Knows uppercase alphabet YES / NO
Knows numbers 1-10 YES / NO
Can follow verbal directions YES / NO
Can follow 1 step directions YES / NO
Can follow sequence pattern YES / NO
Can follow group directions YES / NO
Can write anything YES / NO
Can write letters YES / NO
Can spell YES / NO
Can do addition YES / NO
Can use money YES / NO
Can read anything YES / NO
Communicates with anyone YES / NO
Asks for needed items YES / NO
Can express feelings YES / NO
Domestic Violence: YES/NO
Sexual Abuse: YES/NO
Obesity: YES/NO
Financial Distress: YES/NO
Death of family member or friend: YES/NO
Divorce/Remarriage: YES/NO
Victim or Natural Disaster: YES/NO
Can use spoon and fork YES / NO
Can use stove YES / NO
Knows lowercase alphabet YES / NO
Knows numbers 11+ YES / NO
Can follow written directions YES / NO
Can follow multiple step directions YES / NO
5min focus YES / NO
10min focus YES / NO
Can count YES / NO
Can write name YES / NO
Can write numbers YES / NO
Can copy anything YES / NO
Can do subtraction YES / NO
Can add money YES / NO
Can read simple known words YES / NO
Communicates only when asked question YES / NO
Asks for help YES / NO
Conversation on topic YES / NO
Mobility: walk Y/N; run Y/N; jump Y/N; physical limitations:_____________________________________________
Inappropriate sexual behaviors: Touch self Y/N; Touch others Y/N
Inappropriate vocals: screams Y/N; curses Y/N; mimics Y/N; funny noises (humming, farting, whistling) Y/N __________
Communication: Verbal Y/N; Signs Y/N; Pictures Y/N; Gestures Y/N; AT Device Y/N
Toilet Trained: Urination Y/N; Bowel Y/N
Does your child have a G-Tube? Y/N Does your child required G-Tube feeding for lunch? Y/N
Does your child have any needs that require ongoing nursing care? Y/N
Adverse reaction to: Large Crowds Y/N; sudden loud noises Y/N; sudden change in routine Y/N; transitioning Y/N
Any Obsession items: Y/N_____________________________________________________________________________
Reinforcer items: Y/N ________________________________________________________________________________
Current Concerns: Severity 1= no problem; 2= slight problem; 3= needs treatment; 4= may need more restrictive
placement; P= past problem (>3months ago)
Anything with 3 or higher must be addressed in treatment plan or behavior plan. (Circle all examples that apply)
___ Physical Aggression (hitting, kicking, biting, puling hair, pushing, pinching, other:-_________)
___ Self-Injurious Behavior (cutting, pinching, biting, skin picking, other - ______________)
___ Property Destruction (breaking , throwing , tearing, putting holes in, other - _____________)
___ PICA (mouthing/eating dirt, feces, garbage, toys, coins, other - _______________________)
___ Defiant (argues, tantrums, refuses simple tasks, verbal abuse/cursing, other - ___________)
___ Elopement (leaving defined area, leaving home/school/building, other - ________________)
___ Sexually Inappropriate Behavior (public masturbation, exposing self, other - _____________)
___ Peer Conflict (argues, bullies, provokes, verbal abuse/ cursing, other - _________________)
___ Antisocial Behavior (lying, stealing, setting fires, breaking social rules, other - ____________)
___ Self-Care Problems (enuresis, encopresis, poor hygiene, self-neglect, other - ____________)
___ Other Problem:_____________________________________________________________
___ Other Problem:_____________________________________________________________
Baseline Measures:
Problem Behavior
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Frequency
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Situations that problem behavior always occur are:________________________________________________________
_________________________________________________________________________________________________
Situations that problem behavior never occurs are:________________________________________________________
_________________________________________________________________________________________________
ADDITIONAL INFORMATION:
1. Client Strengths _________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. Client Weaknesses_______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. Preferred Leisure Activities _________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
4. Hypothesized Reinforcers __________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. Family/Support Network Strengths ___________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. Religious/Cultural Sensitivity: □ Yes □ No Describe____________________________________________________
PARTICIPANT WAIVER
OCA PROGRAMS
(RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT)
In consideration of participating in the any OCA program or OCA sponsored event, I/my minor child or ward, (print name or
participant legibly) _____________________________________, represent(s) that I understand the active nature of the programs.
I fully understand that this type of event involves risks of injury, serious bodily injury, including permanent disability, paralysis and
death, which may be caused by my/my minor child or ward’s own actions, or inactions, those of others participating in the event,
the conditions in which the event takes place, or the negligence of the “releases” named below; and that there may be other risks
either not known to me/my minor child or ward or not readily foreseeable at this time; and I fully accept and assume all such risks
and all responsibility for losses, costs, and damages I/my minor child or ward may incur as a result of my/my minor child or ward’s
participation in the event, except for losses, costs and damages that are the result of the gross negligence of others.
OCA Inc., has my permission, (both during and anytime after), to use my (or my minor child/ward’s) likeness, name, voice or words
in either television, radio, film, newspapers, magazines, and other media, and in any form, for the purpose of advertising or
communicating the purposes and activities of OCA Inc., and/or applying for funds to support these purposes and activities, I further
waive any current or future right to seek compensation for said use______ (initial).
OCA utilizes the techniques of Applied Behavior Analysis. We strive for a positive, non-coercive environment. In the event of
crisis, our certified staff will implement Professional Crisis Management Procedures to maintain safety for all participants. For
further information contact Professional Crisis Management Association or visit www.PCMA.org, for clarification.
I further understand that both licensed/leased commercial transportation providers and licensed/approved volunteer, private
transportation providers (OCA Inc.,) could be utilized during the course of any OCA program or OCA sponsored event and
understand that the licensed/approved volunteer, private transportation providers (OCA Inc.,) are included in the following release
and covenant not to sue, under the articulated provisions.
I hereby release, discharge, and covenant not to sue OCA Inc., St. Paul’s Presbyterian Church, their administrators, directors, agents,
officers, volunteers, approved drivers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and
lessors of premises on which the event takes place or utilizes, from all liability, claims, demands, losses, or damages on my account,
except for any liability, claims, demands, losses, or damages caused by the negligence of OCAs Inc., St. Paul’s Presbyterian Church
and or their agents.
I have read this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT,
understand that I/my Parent/Legal Guardian have/has given up substantial rights by signing it and have signed it freely and without
any inducement or assurance of any nature and intend it be a complete and unconditional release of all liability to the greatest extend
allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full
force and effect.
Printed name of participant
Signature of Participant (only if age 18 or over)
Signature of Parent/Legal Guardian
CONTRACT FOR SERVICES
The contract for services rendered will continue from this date ____________________ until terminated by Participant, Legal
Guardian or OCA Inc., or a year from this date.
___ Initial I understand that all participants are on a trial basis and at the end of the trial basis a final decision on continuing the
contract will be decided by the Administrative team. Trial basis are determined by full time or part time status. Full-time
participants= 30 days; Part-time participants= 45 days.
___ Initial The participant’s contract may be terminated, if OCA’s Administrative team has determined that OCA is not the correct
placement for the participant. If OCA is unable to meet the needs of the participant or if participant is endangering other
participants or staff and OCA staff have taken every opportunity and strategy to change/improve participant’s actions. A 30 day
transition time will be given before the withdrawal date; unless it is determined that there is an immediate risk if participant remains
at OCA.
___ Initial I understand that prior to my child participating in Respite, Social Events, Therapy or Camps, he/she must have an inperson observation at OCA.
___ Initial I understand that OCA uses Positive Behavior Supports and Professional Crisis Management techniques to de-escalate
crisis behavior situations.
Scope and Manner of Service
OCA Inc., will provide supervision and care in the participant’s home or in the community on a variable schedule as agreed upon by
the family and OCA. Service requests must be in the office one week in advance of needed service and coverage will be provided as
staff is available. Ongoing services will be arranged as needed. ___ Initial
Sick Policy: If the participant shows symptoms of communicable illness, services should be cancelled with a minimum of 2 hours’
notice. OCA will not send a staff that shows symptoms of communicable illness into your home, but will make every effort to find a
replacement for staff to render services. However, if services cannot be rendered, all monies will be returned. ___ Initial
* Respite and Transportation ONLY: No-show Policy: Family must provide a reasonable amount of notice to OCA and staff when
cancelling services (minimum of 2 hours). If a staff member arrives at scheduled time and the participant is not home within 30
minutes of scheduled time, family will owe staff member a $10 travel fee. ___ Initial
Payment for Services Rendered
The Participant shall pay the Provider for services rendered at a rate agreed upon prior to the date of services. Services can be paid
online, or in our main office by check, cash, or money order. ___ Initial Full payment for contracted services is due even upon
absence for illness, vacation or any other circumstance. ___ Initial Should the Client fail to pay the Provider the full amount
specified, no services will be provided until payment is made.
TRANSPORTATION
___ Initial If transportation is required during a camp or social event, a Right to Transport form will be sent home per event/activity
to be signed.
Cancellation and Refunds
If there is a need for the withdrawal of the participant, a two week notice must be given and a withdrawal date will be
set. If you are unable to complete the two-week notice, a refund will not be made. ___ Initial
Applicable Law
This contract shall be governed by the laws of the County of Orange in the State of Florida and any applicable Federal law.
Signatures
In witness of their agreement to the terms above, the parties or their authorized agents hereby affix their signatures:
________________________________________________
(Printed Name of Client)
____________________________________________
(Printed Name of OCA Representative)
________________________________________________
(Signature of Legal Guardian/Responsible Party)
(Date)
___________________________________________
(Signature of OCA Representative)
(Date)
Rights and Responsibilities
In order to provide quality services, OCA, Inc. wants to ensure that all parties are familiar with the
procedures, rights, and responsibilities.
Procedures:
During the Application process, data will be collected to formulate if OCA is a proper organization for your child. A
decision will be made about the days of attendance .
Your Rights:
1. You will always be treated with respect by OCA, Inc. staff.
2. You will not be discriminated against based on religion, race, cultural beliefs, sex, age, ethnic group, or sexual
orientation.
3. You may terminate services at any time, requiring a 2 week notice.
4. Your personal information will be protected as per the HIPPA Law.
* We are required to break confidentiality/privacy in the event of the following:
Reporting suspicion of child/elder/disabled adult abuse or neglect.
Releasing information for the purpose of abuse/neglect investigations.
Need arises to warn potential victims if we believe their lives are in danger.
Required documents/records that are listed in subpoena for court testimony.
5. You may view a copy of your records at any time, with written notice.
6. You may make a complaint by contacting the Program Director without fear of retaliation or termination of
services. If you are unhappy with the Adult Vocational Training, you are to address your concerns with the Program
Director. If you do not feel your concerns have been addressed you then may address your concerns with the Executive
Director.
Your Responsibilities:
Your family is responsible for keeping your scheduled days of attendance and picking up on-time 5:30, unless
otherwise stated.
If your family's contact information changes, you will let the Program Director or Administrative Assistant know.
Payment is expected prior to the delivery of services.
Our Rights and Responsibilities:
1. We will provide you high quality service from trained professionals who are actively refreshing their clinical skills
through education, workshops, and supervision.
2. We will keep accurate data.
3. We may terminate services in the event that the above listed participants responsibilities are not completed or if
we believe that continuation of services will not provide further benefit on the treatment goals. A 30 day
transition time will be given before the withdrawal date.
_________________________________________________
______________________
Parent/Caregiver/Legal Guardian
_____________________________________________
Signature of OCA Representative
Date
____________________
Date
In Case of Emergency
Participant Name:________________________________________________ DOB:_____________________________
Phone: Home:_________________ Cell:______________________ Email: ____________________________________
Home Address: _____________________________________________________________________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Primary Emergency Contact Name:_____________________________________ Relationship:_____________________
Phone: Home:______________________ Cell:___________________________ Work: ___________________________
Secondary Emergency Contact Name:__________________________________ Relationship:______________________
Phone: Home:______________________ Cell:___________________________ Work: ___________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Insurance Company: _________________________________________ Policy #:_________________________________
Preferred Hospital: __________________________________________________________________________________
Current Medications/dosages/times: __________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________ _________________________________________________________________________
Allergies: __________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Seizure history: Last date and time: _____________________________ Frequency: _______________________
Medical Diagnosis: __________________________________________________________________________________
__________________________________________________________________________________________________
Other medial issues: _________________________________________________________________________________
__________________________________________________________________________________________________
How does your participant communicate: _______________________________________________________________
Participant’s receptive comprehension ability: ___________________________________________________________
Anything else the doctor may need to know: (fears, dislikes, things that may make situation better, etc) _____________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
As parent/guardian with legal responsibility for __________________________________ I acknowledge by signing
below I am giving permission for trained OCA personnel to administer first-aid and/or medication in cases of minor
injury/illness. In cases of serious injury and/or illness, emergency services will be called and/or participant will be
transported to emergency services.
As parent/guardian with legal responsibility for this participant, I further agree to bear all cost of emergency services
provided in case of injury or illness. ____________ (Initial)
Signature:________________________________________________________________ Date:____________________
OCA After School Program
DISCIPLINE/PARTICIPANT EXPECTATIONS
All discipline infraction will be handled according to OCA’s Participant Expectations. I have read OCA’s Participant
Expectations___ Initial Discipline infractions may result in possible expulsion from OCA After School Program.
___ Initial
ACCOMMODATION CLAUSE
OCA will provide accommodations to participants with disabilities, provided these accommodations do not pose an
undue hardship on the organization or jeopardize the safety of other participants, volunteers or employees.
Management reserves the right to make all program-related decisions on reasonable accommodations. By enrolling
your participant in the program, you agree that your participant does not have aggressive behaviors, has minimal
transition issues, is able to use restroom facilities with minimal assistance, and is able to eat snacks with little
assistances. If there are any questions regarding a participant’s ability to participate in our program, OCA may request
that your participant be placed on a behavior plan. Please not that we are not able to provide one-on-one supervision of
your participant.
PAYMENT PROCEDURES
A $15.00 non-refundable registration fee is due at the time of registration. Payments are to be made using a
check or money order payable to OCA, cash or payment online at: GoOCA.org for the exact amount of $65.00
& for each additional participant, add $50.00. All payments are due by the Friday prior to the start of each
new week.
**Minimum 3 days for Part-time: $15.00 a day
** If school week is 4 or 5 days, the price of After School is $65.00
If you arrive after 5:30pm there is a $1.00 fee for every minute that you are late. You must notify the After
School Program in advanced if you will be late.
If for any reason your check is returned by your bank, it will be collected electronically through a third party agency.
A $35.00 fee will be charged each time this service is utilized. OCA is not responsible for these collection fees.
Full payment for contracted services is due even upon absence for illness, vacation or any other circumstance.
___ Initial
By signing below, I hereby state that I have read and understand the above listed policies and information.
Parent/Guardian Signature: ___________________________________________________________
Parent/Guardian Printed Name: ________________________________________________________
Date: _______________________________
Authorization for release of behavior and school information
By signing this document, I, _____________________________________
Parent/guardian of _____________________________________________,
(DOB ______________), hereby authorize __________________________, to disclose the
above named minor's information and records obtained in the course of the minor's
assessment with OCA, Inc.
This disclosure of information and records authorized herein is required for assessment
purposes.
The specific uses and limitations on the types of medical, behavioral, and school information
to be disclosed are as following: All information required to complete the intake form for
attendance to OCA, Inc.
OCA, Inc. will not share this information with any external entities.
This authorization shall remain valid for one year following the date signed below.
__________________________________ Date______________________
Signature of Parent/Guardian
__________________________________ Date______________________
Signature of Minor
*PLEASE SEND NEXT PAGE TO YOUR CHILD’S CURRENT TEACHER OR THERAPIST*
OCA SCHOOL AGE INTAKE FORM – Teacher/Therapist input form
Child’s Name:
Toilet trained: Urine:
Bowel Movement:
School:
Teacher name:
School #:
Email:
Required ratio: 1 staff to ?students
Student’s Interests:
Communication: Verbal:
Signs:
Pictures:
Gestures:
AT Device:
Gross motor movements:
Walk:
Run:
Jump:
Physical Limitations:
How does the student react in a large
crowd?
How does the student react to sudden
loud noises?
Transitions: How does the student act
when leaving a preferred activity to
another?
Helpful tips:
Any obsession items:
SIB: description:
Reinforcement items:
Aggression: description:
Transitions: How does the student act
when leaving a preferred activity to an
un-preferred activity?
Elopement: runs, walks, wanders
Antecedent to behavior:
Inappropriate vocals:
Screams:
Curses:
Mimics:
Funny Noises
(humming, farting, whistling):
Pica: does the student eat anything
other than food?
Any nonsense behaviors:
Additional Comments:
Inappropriate sexual behaviors:
Touch self:
Touch others: