Crow Creek Tribal Schools

CROW CREEK TRIBAL SCHOOLS

Dormitory Application

2013-2014

CCTS Residential Program State of Purpose

The Purpose of the CCTS Dorm is to provide a traditional home-living environment to students attending Crow Creek Tribal Schools. We are not a therapeutic dormitory, so we may not be able to meet the need of all students. All student applications will be reviewed by the dormitory committee to determine if the CCTS residential program can meet each student’ residential needs. A waiting list will be as application come in to the CCTS Dorms for the new school year.

Application Deadline

The dorm application deadline is July 26th. Any applications received after this deadline will be considered if space is available.

Attendance in the Dorms

Because we only have space for 50 girls and 50 boys in the new dorms, we want to keep our attendance high throughout the entire year. We hope that the students and their parent/guardian will make a strong effort to be with us for the entire school year once they are accepted. Whenever a student is out of the dorm for 10 consecutive days, they will be dropped from the dorm (as required by BIE) and their name will be placed at the bottom of the waiting list. The next person on the waiting list will be contacted and invited into the dorms. We appreciate your understanding and look forward to providing a safe and enjoyable residential experience for the 2013-214 school year.

Other Notes:

Be sure to have your CHECK-OUT FORM NOTARIZED.
Health forms are important to fill out (both off-reservation and local students)

Crow Creek Tribal Schools

2013-2014 Dormitory Application

105 Chieftain Loop, Stephan, SD 57346

Appendix B-Charges for Damages caused by students

The following are amounts which could be charged in the event you son/daughter was to cause damage to the dorm either by intention or as a result of misconduct.

Damage to dorm cause by student:

Broken Window $100Hole punch in wall $50Door $300

Wardrobe/Hasp Damage $50Combination lock $15-$25 Graffiti Clean-up $25

Fire Extinguisher Cover $75Bathroom/Shower Damage $100

Damage to furniture, causing replacement values to be considered: (freight might also be charged). These prices are based on the actual costs of furniture as ordered by BIA.

Wardrobes $485Bed $295Mattress $140Drawer $140Desk $295

Chair $125Nightstand $310Desk/Chair $165Table $385Stool $30

Foosball Table $530Round Table $320Coffee Table $180End Table $180

Bookcase $120Table w/Ped & Footrest $365Pool Table $4,400

Lounge Table $320

I understand that if my son/daughter damages any dorm property, I will be included in the discussion and investigation. I also agree that should my son/daughter be found liable through either misconduct or willful actions, I will be responsible for any reasonable charges, which might include freight.

______

Student’s NameStudent’s Signature

______

Parent/Guardian SignatureDate

Crow Creek Tribal Schools Dorm Application Packet for Students6/13/11

{The Home Living Specialist will call each parent/guardian to review,prior to approval.}

[Failure to provide an accurate response to all questions can result in denial of application or your child’s immediate release from the CCTS Dorms.]

Section I: Educational History

Student Name: ______Date: ______

Parent/Guardian: ______. Relationship to student: ______

Phone #s: Home ______Cell ______Work ______

Other phone #s for emergencies: ______; ______.

Mailing Address: ______City ______State ______

Check boxes below to indicate previous and current educational placements, if known.

Kind of Placement (check all that apply) / Previous / Most recent
Regular Classroom /  / 
Regular Classroom with in-class support and/or accommodations /  / 
Special Education Classroom/Resource Room /  / 
Alternative School /  / 
Treatment Program /  / 
Residential School and Dorm /  / 
Home and/or Hospital-based Instruction /  / 
Not in school – suspended /  / 
Not in school – expelled /  / 
Please describe educational placement(s)checked above:

Section II: Living Situation History

Check boxes to indicate previous and current living situations, if known.

Type (check all that apply) / Previous
(Before) / Current
(Now)
One Parent (indicate Mother or Father): /  / 
Relatives /  / 
Foster Care /  / 
Group Home /  / 
Emergency Shelter /  / 
Residential Treatment (non drug/alcohol) /  / 
Drug/Alcohol Residential Treatment Program /  / 
Medical Hospital /  / 
Psychiatric Hospital /  / 
Juvenile Center (JDC) /  / 
Correctional Facility (i.e. Custer) /  / 
Has a child /  / 
Has fathered a child or been pregnant /  / 

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Crow Creek Tribal Schools – Dorm Application Packet for Students

Section III: Behavioral Issues

Student’s Name: ______Date: ______

Note to Parents/Guardians: Your providing accurate information will help us provide your child with the best possible services to help her/him have a successful year in our dorm.

Has the child or youth ever exhibited any of the behaviors listed below? If yes, check those that apply.
 Shows strong emotions /  Impulsive /  Stealing
 Extreme sadness /  Anxiety /  Depression
 Runs away /  Mood changes /  Hard time sleeping
 Eating disorder /  Hyperactivity /  Bladder/bowel problems
 Not accepting authority /  Refusal to accept limits /  Argues with others
 Verbal aggression /  Self-injurious behavior /  Persistent school refusal
 Anger towards self /  Anger towards others /  Cutting
 Expressed aggression towards people /  Expressed aggression towards property /  Tends to avoid social contact with others
 Expressed thoughts of suicide /  Shown suicidal behavior /  Suicidal attempts
 A family member or very close friend has committed suicide
 Has a social services case worker /  Extreme withdrawal from family /  Serious sleep disturbance
 Fire setting/fire play /  Animal cruelty /  Problems with the law
 Missed more than 10 days of school last year /  Suspension (out of school) during past year /  Expelled from school during the past two years
 Huffing inhalants (paint, hairspray, glue, nail polish) /  Huffing “dusters” (aerosol air cleaners - to clean key-boards, etc.) /  Huffing alcohol-based products or other aerosol-type products
 Substance abuse /  Experienced trauma /  Inappropriate behavior
 Has been arrested /  Has a probation officer /  Bullying
 Special concerns or counseling help you would like to see for your child: (please list)
New Policy for all dorm students-2013-14 School Year: For your child’s safety parents/guardians must agree with allowing the dorms to test their child for mood altering substances if there is reason for concern. In this cause you will be notifies of the reasons for this concern and the testing results.
I give my permission for my son/daughter to be tested. I understand this is for their safety, and that of the dorms. I also understand that I will be contacted both before and after this testing.
Signature of Parent/Guardian:______

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Crow Creek Tribal Schools – Dorm Application Packet for Students

Section IV: Social History – Counseling Information

Student’s Name: ______Date: ______

[Failure to provide an accurate response to questions can result in denial of application or your child’s immediate release from the CCTS Dorms.]

Has your child received any out-patient counseling or therapy for substance abuse, mental health or behavioral issues? _____Yes _____No

If yes, please identify and describe what kind and have the Counselor or therapist send a report and recommendations to the Dorm Counselor, Crow Creek Tribal Schools Dorms.

Why did they seek counseling? ______

Name & Title of Counselor or Therapist: ______

Address: ______

Phone Number: ______Date(s) of Counseling: ______

Has your child ever received in-patient services treatment program for substance abuse, mental health or behavioral issues? ______Yes _____ No

If yes, please have the treatment program send a report and aftercare recommendations to the Dorm Counselor, Crow Creek Tribal Schools Dorms.

Did they complete this? ____ Yes ____ NoWas this helpful? ____ Yes ____ No

Name of Treatment Program: ______

Address: ______

Phone Number: ______Date of Treatment: ______

Has your child ever been arrested? _____ Yes _____ No

Has your child ever received services from a correctional program? ____ Yes ____ No

If yes, explain. ______

Please have the facility send a report & recommendations to the CCTS Dorm Counselor.

Name of Correctional Facility: ______

Address: ______

Phone Number: ______Date of admittance: ______

Does your child have a Social Worker or Probation officer? If so, please provide name and contact information. ______

Has your child ever been arrested or charged with a sexual offense? ____Yes ____No

Has your child ever been a victim of sexual abuse? _____Yes _____No

If yes for either, please describe: ______

______

If yes, has your child/youth been in counseling? ____ Yes ____ No

Section IV: Social History, Continued. Student’s Name: ______

Has your child displayed any anger against others or themselves? ____ Yes ____ No

If yes, please explain. ______

Does your child use “cutting” as a way to solve problems? _____ Yes _____ No

If yes, please explain.

______

What is the cutting behavior? (i.e. possibly using a razor to cut their arms.)

______

Has your child missed more than ten days of school during the past school year?

_____ Yes _____ No If yes, please explain: ______

Has your child been expelled during the past school year? _____ Yes _____ No

If yes, please explain:

______

Has your child received an out-of-school suspension during the last school year?

If yes, please explain: ______

Do you have any special concerns for which you would like the counselor to be aware?

______

List any medications your child has been prescribed during the past year:

Name of medication(s) / Dosage / How often taken?

Consent for Counseling Services

I give permission for my child to receive counseling services from Crow Creek Tribal Schools or through Indian Health Services in Fort Thompson, SD. I understand that this service will be given if and when my child’s behavior indicates the need. I understand that if I do not give consent for counseling services, I must provide an outside source for counseling if deemed necessary.

I also give my permission for my child to be checked for cutting by medical personnel, should this become a concern.

______

Parent/Guardian (print)Signature of Parent/GuardianDate

Crow Creek Tribal Schools

DAY Student Check out Form – 2013 - 2014

(Dorm students must use the Dorm Check-Out Form when checking out during school.)

It is very important the Parent/Legal Guardian have this form complete and notarized for the safety of our students. Students will not be allowed to check out of the dormitory or school unless they are released to a person whose name appears on this permission form. Any other special circumstances will have to be referred to a Principal, Dormitory Supervisor or Superintendent.

______

Student NameHome Reservation

______

Parent/Legal GuardianPhone # you can be reached at immediately

______

PO Box/AddressCityStateZip

I hereby give the following adults permission to check out my son/daughter for week-ends or holidays.
I understand that these adults must personally pick up the student and sign him/her out from the school (if during school hours) and from the dormitory.
I understand that off reservation students may not check out to Ft. Thompson and surrounding communities for overnight unless with parents or legal guardian.

(Handwriting must correspond to notarized signatures at bottom of the page)

______

I also give the school permission to seek out adequate housing and transportation for my son/daughter during emergencies.

______

Signature of Parent/Legal GuardianVerified by Notary of the Public

SDHSAA FORMS INSERTS ARE ATTACHED TO THE NEW STUDENT APPLICATION

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