Stepping Stones School 19 Harrison Avenue Roseland, NJ Phone:(862) Fax: (862)

Transcription

1 Stepping Stones School 19 Harrison Avenue Roseland, NJ (862) Fax: (862) Dear Parents/Guardians: School of Excellence Welcome to the Stepping Stones school year. Each school year the administrative staff sends home forms for completion by either yourself and/or your child s doctor. Please review, complete and return the forms listed below before or on your child s first day of class to the following address: Stepping Stones School 19 Harrison Avenue Roseland, NJ Attn: School Nurse o General Information Sheet o Student Contact and Directory Sheet o Photo Release o Library Policy and Procedure o Illness/Injury Policy ( Danielle s Law ) o Identifying Life Threatening Emergencies Fact Sheet o Health Care Contract o Medical Data and HIPAA Form o Emergency Medical Treatment Release Form o Over the Counter Medication Sheet o In School Medication Form (if needed for regular or as needed administration of any prescription medications in school) o Medical Data Sheet and Medical Information/Physical Exam (medical provider s signature & updated copy of child s immunization record required with this form) o Influenza and pneumococcal vaccine information form o Sneaker & backpack information o School Nurse Calendar for school year and School Calendar for school year We thank you in advance for your cooperation. If you have any questions please do not hesitate to contact either the Main Office or the school nurse by dialing the main number and pressing 6. Sincerely, Marvin Leiken Principal

2 Stepping Stones School 19 Harrison Avenue Roseland, NJ (862) General Information: School Year Schedule: A calendar for the school year is enclosed. Classes run from 8:50 a.m. to 2:40 p.m., Monday through Friday during the regular school year. Our extended school year program operates during July/August, Monday through Friday from 8:30 a.m. to 1:30 p.m. Transportation: Transportation arrangements are provided by the student s sending district or by personal means. It is the parents/guardians responsibility to contact the transportation company with any issues: timeliness, condition of bus, aide on the bus, driver concerns, etc. Please ensure that if your child requires a car seat that one is provided on the van please contact your individual company for these arrangements. If a parent chooses to transport their child, the parent must wait in the transportation pick up/drop off line. Your child will be brought to you. Health Records: The New Jersey State Department of Health requires certification by a pediatrician that the DPT shots (diphtheria, pertussis and tetanus), Polio series, measles, German measles (rubella), chicken pox and mumps shots have been administered before entry into the Stepping Stones School. An annual flu shot and a minimum of one (1) pneumococcal immunization is also required for students ages 5 and under (see attached Parent Immunization letter for additional information). Illness/Medication: If your child is out of class because of illness or any other reason, please notify the school before 8:00 a.m.; you can leave a message on the main number or Health Office voic if you are unable to reach a staff member directly. Parents are advised to keep a child home if there is any sign of illness. This is important for both his/her protection as well as the protection of other children in class. (see the enclosed Health Contract for more specific information.) Medications (prescription and over the counter) can only be administered in school with an original doctor s note/order. Also: please let us know when your child is taking any prescription or over the counter medications at home (i.e.: ADHD medications, allergy, Tylenol, Sudafed, etc.) or when there are any changes in your child s medications. If your child is currently without health insurance you can visit for enrollment information. Weather Information: In emergency situations, such as snowstorms, the school may have a delayed opening, early dismissal or close. You will be notified by the One Call system of any schedule changes. It is the parent s responsibility to then call their transportation company with this information regarding school delays, early dismissal and closings. Children Who Are Toilet Trained: Please provide a complete change of clothes. Children Who Are Not Toilet Trained: Please provide a complete change of clothes and diapers. Clothing: Please send your child to school in clothes that cover their midriff and wear shorts or leggings under skirts/dresses. Shoes The children are engaged in physical activities every day. To ensure the safety of your child, please have your child wear sneaker type shoes or supportive, closed toe shoes. If your child arrives at school in shoes that are not appropriate for physical activities they may not be able to participate in all school activities. Snack/Lunch Lunch is not provided; please provide lunch food in accordance with our therapeutic feeding program. Snack is provided so please alert the school nurse if your child has any food allergies or sensitivities.

3 Stepping Stones School 19 Harrison Avenue - Roseland, NJ (862) Fax: (862) Principal Cell: (973) JULY AUGUST SEPTEMBER OCTOBER NOVEMBER School Hours: 8:50am 2:40pm July 4 July 5 Aug. 15 Sept. 1 Sept. 4 Sept. 5 Sept. 6 Sept. 7 Oct. 3 Oct. 6 Oct. 9 Oct. 20 Oct. 31 Nov. 1,2,3 Nov. 21 Nov. 22 Nov. 23 & 24 Dec. 14 Dec. 22 Dec Jan. 1 Jan. 2 Jan. 15 Feb. 12 Feb Mar. 15 Mar. 30 Apr. 2 6 May 28 June 6 June June 19 Early Dismissal: 1:00pm ESY (July and August) 8:30 am 1:30 pm Independence Day School Closed Wed.: First Day of ESY Tues.: Last Day of ESY School Closed Mon.: Labor Day School Closed Tues.: Staff Development School Closed Wed.: Staff Development School Closed First Day for Students Back to School Night Fall Fes val Columbus Day School Closed Grandparents Day Halloween Party Conferences (1 PM Dismissal) Students Only Thanksgiving Feast Thanksgiving Break (1PM Dismissal) Students Only Thanksgiving Day School Closed Holiday Party/Santa (1 PM Dismissal) Students Only Winter Break (1 PM Dismissal) Students Only Winter Break School Closed New Year s Day Observed School Closed Tuesday School Reopens Monday MLK Day Observed School Closed Staff Development (1PM Dismissal) President s Day Break Staff Development (1PM Dismissal) Good Friday School Closed Spring Break School Closed Memorial Day School Closed Volunteer Luncheon (1 PM Dismissal) Students Only 1 PM Dismissal Students Only Last Day of School/Gradua on 1 PM Dismissal for Students Number of School Days: July 19 January 21 August 11 February 17 September 17 March 21 October 21 April 16 November 20 May 22 December 16 June 13 JANUARY FEBRUARY MARCH APRIL MAY DECEMBER *This calendar provides 214 days of school and allows for 4 snow days. Addi onal snow days will be made up by reducing the last day of spring break. In the event snow days are unused they will be returned. Closed 1:00 Dismissal Staff Development/School Closed Staff Development/1:00 Dismissal Students Only JUNE

4 Stepping Stones School 19 Harrison Avenue Roseland, NJ STUDENT CONTACT INFORMATION & DIRECTORY SHEET Please complete this form and return to Stepping Stones. (PLEASE PRINT CLEARLY) Include info in the Student Directory? Name of Student: YES NO Date of Birth: Age: Sex: YES NO Address: (Number & street) YES NO (City) (State) (Zip) Name of Parents/Guardian: Home Phone Number: Cell and/or Business Phone Number(s)and YES NO YES NO YES NO (Father Cell): (Father Business): (Mother Cell): (Mother Business): Father Mother (All information included below this line will NOT be included in the Student Directory): Name and phone number of relatives/friends/neighbors who can be contacted in case of emergency: (Name) (Phone #) (Relationship) (Name) (Phone #) (Relationship) By signing this form you consent to the entry of your contact information into the One Call phone alert system. Date Signature of Parent or Guardian

5

6 *Photo releases will remain in effect, unless The Arc of Essex County is notified in writing.

7 Stepping Stones School 19 Harrison Avenue Roseland, NJ (862) Dear Parents, We are happy to announce, through generous donations and grant money, that Stepping Stones continues to expand their lending library for the school year. This year, every class will have a library session once a week. During library time, students will be able to browse through books and select one to check out. This book will remain in the classroom on school days, and will go home on Friday to share with you. Please remember to return your child s library book on Monday morning. In order to maintain a full supply of books, we cannot allow a new book to go home until the old one is returned. If your child s library book gets lost or damaged there will be a flat fee of $5 to replace the book. We are looking forward to making our lending library an exciting and educational experience for our students! Thank you, Stepping Stones Staff Stepping Stones Lending Library I have read the above and understand the library policy and procedures. Parent/Guardian Signature Child s Name

8 The Arc of Essex County STEPPING STONES SCHOOL 19 Harrison Avenue Roseland, NJ (862) MEDICAL DATA SHEET Student Last First Physician information Please ensure primary physician & District CM are named on the HIPPA form. Pediatrician (Primary) Dentist Endocrinologist ENT Orthopedist Cardiologist Eye Doctor (Other) MEDICAL PROCEDURES: Please provide a list of any procedures/surgeries the child has had PROCEDURES/SURGERIES DATE

9 Student s School Year Medical Information: Date of last eye/vision exam: Results: Does the child wear glasses? Yes No Reason for glasses: Date of last Atlanto-axial Instability Screening Results: Date of last hearing exam Results: Date of last thyroid blood test (if applicable) Results: Date of last dental visit Results: Date of physical exam (please provide): Physical Exam N = Normal R = Referred T = Under Treatment C = Comments Ears (otoscope) Nose Chest/ Lungs Orthopedic Eyes Lymph Glands Thyroid Neck/ Throat Oral/Teeth CV/Heart Abdomen/ Back Hernia Feet/ Extremities Genito- Urinary Posture Skin/Scalp Nervous System Speech Other/Labs Nutrition General Appearance Height Weight TPR + BP IMMUNIZATIONS: attach a legible copy of the child s most recent immunization records Are there any other conditions, activity restrictions or information we should know about? YES NO Allergies? YES NO If Yes to either, please describe below: The signature of the physician/provider is required. Date Physician Name PLEASE PRINT Signature Provider Stamp Here

10 STEPPING STONES SCHOOL Emergency Medical Treatment Release Form Students Sex: M F As it appears on the Last First Circle one Birth certificate Date of Birth: Please indicate the order in which we should call in case of an emergency using 1, 2, 3 Mother/Guardian Home Address: Work Cell Father/Guardian Home Address: Work Cell Additional person(s) authorized to pick up child and/or contact in the event of an emergency Name Phone Number Relationship Allergies: Does your child have any allergies to food, medication, insects, latex, environmental triggers, etc? If yes, please list & indicate if epipen/medication prescribed: Health Conditions: Has your child currently or in the past been diagnosed with any of the following? Check all that apply: Yes No Yes No Yes No Asthma Epilepsy/Seizures Hearing problems Diabetes ADD/ADHD Chronic illness Heart Problems Vision problems If yes to any of the above, please specify: Yes No Please list any procedures/activities that must be avoided: Medications: Please list any prescriptions or over the counter medications given to your child regularly at home/in school Medication Name Dosage Frequency Does your child wear/use any prosthetic/internal devices? Yes No (circle) Specify: Primary Care Physician Phone Number Name of Insurance Carrier/Medicaid Policy # If in the judgment of any responsible person employed by The Arc of Essex County Stepping Stones School, the above named student needs immediate care, medication and treatment as a result of any injury, illness, emergency medical situation or sickness, I (we) do hereby request, authorize and consent to such care and treatment that may be given by any medical professional or school representative. I (we) give permission for transportation by ambulance or other insured vehicle to an emergency facility. I (we) hold harmless the Arc of Essex County, its employees and/or agents who acts in good faith to provide immediate care or treatment to the above named student. I release the Arc of Essex County Stepping Stones School and its employees from all liability in connection therewith. Parent/Guardian Signature and date Parent/Guardian Signature and date Two signatures are not required for validity, but both parents/guardians are requested to sign

11 STEPPING STONES SCHOOL OVER THE COUNTER MEDICATION SHEET The following over the counter (OTC) medications may be given to the student, if necessary, during the school year. OTC meds for skin rashes, nasal saline spray and sunscreen must be provided by the parent(s) Physician: Please specify the dosage, frequency and route for medications selected. Student Name Sex: M F As it appears on the Last First (Circle) Birth Certificate Date of Birth Allergies General Pain Children s Tylenol 160mg/5ml Dosage Frequency Route Children s Motrin 100mg/5ml Dosage Frequency Route Other: Dosage Frequency Route Temperature/Fever Children s Tylenol 160mg/5ml Dosage Frequency Route Children s Motrin 100mg/5ml Dosage Frequency Route Other: Dosage Frequency Route Skin Rash/Skin Irritation Zinc Oxide cream Apply to Frequency: A+ D ointment Apply to Frequency: Other: Apply to Frequency: Nasal Saline Spray Apply to Frequency: Indications for use: Nasal congestion/discharge/mucus Sun Protectant Sunscreen (brand name) Apply to Frequency: Physician Name (please print) Signature Date Provider Stamp Here Parent/Guardian Name (please print) Signature Date Both the signatures of the physician and parent/guardian are required Parents/Guardians: by signing this form you give the school nurse permission to administer your child s medications as prescribed by the physician/medical provider.

12 The Arc of Essex County Stepping Stones School 19 Harrison Avenue Roseland, NJ (862) Fax (862) IN SCHOOL MEDICATION/TREATMENT FORM A separate form must be completed for each medication/treatment administered at school. Student Last First D.O.B. This section is to be completed by the Health Care Provider Name of medication/treatment Date to commence Allergies: Date to discontinue Form of medication and/or Treatment Reason for medication Dosage amount/frequency/route Tablet/Capsule Liquid If other, please specify: Restrictions/Side Effects If PRN, provide indications for giving medication/treatment Provider s Printed Name Signature and date Address: This section is to be completed by the Parent/Guardian Inhaler Nebulizer Injection Other Dosage Frequency Route Effects: No Yes If yes, please describe: As per Department of Education Regulations, please bring/send this form and the MEDICATION IN THE ORIGINAL CONTAINER to school. Medication will not be administered if it is not accompanied by this form and in the original container. The medication container must have the name of the student, the name of the medication and directions on the pharmacy label in order for it to be accepted and administered by the school nurse. This form will be in effect for one (1) calendar year unless indicated otherwise. THERE ARE NO EXCEPTIONS I request and give permission for the school nurse to administer the above medication/treatment to my child. Child s name Provider s Stamp Here Signature of Parent/Guardian This section is to be completed by the School Nurse Date Date Form received: Medication/supplies properly provided? Yes No Nurse s Signature:

13 Stepping Stones School 19 Harrison Ave. Roseland, NJ (862) June 2017 Dear Parents and Guardians: With the upcoming summer months many parents and guardians schedule annual check-ups for their children. The enclosed information will help you ensure that your child s immunizations will be up to date for the upcoming school year. As of Sept. 1, 2008 New Jersey enacted rules that made the flu shot and a shot to prevent pneumonia mandatory for preschoolers. All children going to day care or preschool programs are REQUIRED to get an annual flu shot and a one-time pneumococcal vaccine as follows: N.J.A.C. 8: Pneumococcal conjugate vaccines Every child 12 months through 4 years 11 months of age enrolling in or attending child-care center of preschool facility on or after Sept. 1, 2008 must receive at least one (1) dose of pneumococcal conjugate vaccine on or after their first birthday. Please note that children must receive the pneumococcal vaccine by Sept. 1, 2016 for the upcoming school year. N.J.A.C. 8: Influenza vaccines Children six months through 4 years 11 months of age attending any child-care or preschool facility annually must receive at least one dose of influenza vaccine between Sept. 1 st and Dec. 31 st of each calendar year. There is no grace period for unvaccinated children. Per state law, students who have not received the influenza vaccine by Dec. 31 st must be excluded from the child care/preschool facility for the duration of the influenza season (through March 31 st ), until they receive at least one dose of the influenza vaccine or until they turn 60 months (5 years) of age. Please feel free to share this information with your child s primary care provider. If there is a medical why your child cannot receive the immunizations a letter must be written by your provider stating the reason and a copy provided to the school. If you have any questions please do not hesitate to contact me; additional information is also available at qa.pdf. Very truly yours, Beth Patterson, RN School Nurse

14 NJ Department of Health/Reportable Communicable Diseases Confirmed or Suspected Cases for Immediate Notification of Local Health Department: Anthrax Botulism Brucellosis Diptheria Foodborne intoxications (shellfish poisoning, mushroom poisoning, etc.) Haemophilus influenza, invasive disease Hantavirus pulmonary syndrome Hepatitis A, acute Influenza, novel strains only Measles Meningococcal invasive disease Outbreak/suspected outbreak of foodborne/waterborne/nosocomial disease or a suspected act of bioterrorism Pertussis Plague Poliomyelitis Rabies (human illness) Rubella (German measles) SARS Smallpox Tularemia Viral hemorrhagic fevers (including but not limited to Ebola, Lassa & Marburg viruses) Reportable Within 24 hours to the Local Health Department: Amoebiasis Animal bites treated for rabies Arboviral disease Babesiosis Campylobacteriosis Cholera Creutzfeldt-Jakob disease Cryptosporidiosis Diarrheal disease Ehrlichiosis E. coli Giardiasis Hansen s disease Hemolytic uremic syndrome Hepatitis B & C HIV/AIDS Influenza related pediatric mortality Legionellosis Listeriosis Lyme disease Malaria Mumps Psittacosis Q fever Rocky Mountain Spotted fever Rubella Salmonella Shigelosis Resistant S. aureus Strep disease, invasive groups A & B Strep pneumonia Strep toxic shock syndrome Tetanus Toxic shock syndrome (other than strep) Trichinellosis Tuberculosis Typhoid fever Varicella (chicken pox) Vibriosis Viral encephalitis Yellow fever Yersiniosis

15 Stepping Stones School Health Care Contract: School Year Stepping Stones understands that it is difficult for a parent to leave or miss work; therefore, it is suggested that parents/guardians make alternative arrangements for occasions when children must remain at home or be picked up from school due to illness. For the continued health and safety of your child it is important to always inform the school nurse whenever your child has an illness, injury, surgery or medical procedure. If your child has any of the following conditions or symptoms we will contact you to make arrangements to pick up your child from school (within 1 1 1/2 hours) in order to prevent contagion of other children and staff and to ensure the comfort of your child. Please be aware that we are unable to keep sick children in the Health Office until the end of the school day as this impacts health services to other students. Fever accompanied by other symptoms (temperature of 100 o F taken by mouth, 99 o F under the arm, or 101 o F taken by ear). Any rash suspicious of contagious childhood disease. Vomiting accompanied by other symptoms (fever, vomiting, rash, crankiness, or vomiting 2 times or more in a 24 hr. period, etc.) Diarrhea accompanied by other symptoms (fever, vomiting, rash, crankiness, etc.) or uncontrolled diarrhea (stool runs out of diaper or child unable to get to the toilet on time). Any skin rash, lesion or wound with bleeding or oozing clear fluid or pus. Red eyes with white or yellow discharge. Mouth sores with drooling. Scabies, head lice or other infestations. Constant, uncontrolled yellow or green nasal discharge or constant, uncontrolled cough. Complaint of throat pain (or evidence of throat pain) with inability to eat or swallow. Any illness or condition requiring one-to-one care. Any condition preventing the child from participating comfortably in usual program activities. Any contagious illness which is reportable ** to the Department of Public Health. Please note per NJ state regulations children who are exempted from immunization for religious or medical reasons may be excluded from Stepping Stones during a vaccine preventable disease outbreak or threatened outbreak. After a child was excluded for any of the above reasons the following conditions must be met in order to return to the program: A child must be free from fever, vomiting, diarrhea (without symptoms or administration of medication to control these symptoms) for a FULL 24 HOURS. Any child prescribed an antibiotic for a current bacterial infection must take the prescription for a FULL 24 HOUR course before returning to school.

16 A child must be able to participate comfortably in all usual program activities, including outdoor time. The child must be free of open, oozing skin conditions unless: 1) a health care provider signs a note stating that the condition is not contagious and 2) the involved area(s) can be covered by a bandage without seepage of drainage through the bandage. A child excluded because of lice, scabies or other infestation may return 24 hours after treatment has begun with a note from a doctor stating the child is larvae or nit-free. If a child was excluded because of a reportable**contagious illness, a doctor s note stating that the child is no longer contagious is required prior to re-admission. A doctor s note is required if the child is absent for three (3) consecutive days or more. Children with immunization exemptions may return to school when the risk posed by the vaccine preventable disease outbreak has passed. ** The state of New Jersey publishes a listing of communicable diseases (i.e measles, whooping cough, tuberculosis, etc.) which must be reported to the Department of Health upon diagnosis. A list of these diseases is attached for your reference. If your child has had surgery, a medical procedure, or an illness/injury that may impact their ability to safely and comfortably participate in school activities a medical clearance from your doctor is required in order for your child to return to school. Please note that: The doctor should state in writing the date the child may return to school and the date the child may resume their therapies (please note these dates may not be the same). If necessary, the doctor can specify on the medical clearance any activities or movements the child should not do following the surgery, medical procedure or injury. Copies of our Medical Clearance forms Post Surgery and Illness/Injury are attached for your convenience; please feel free to copy these blank forms as needed or notify the school nurse if you need additional forms. If your child should undergo surgery/medical procedure or sustain an injury during the school year please return these completed forms signed by the medical provider on the first day your child returns to school; please note that you will be contacted to take your child home if these forms are not provided. If your child returns to school post illness, etc. without a note from your doctor your child may have to go home if it is determined your child is in pain, showing signs of illness or is in a condition which may be unsafe to self or others. If your child remains at school they may be restricted from participating in certain therapies or activities until a medical clearance is received from the doctor. The final decision whether to exclude a child from the program is made by the school administrator. Child s Name (PLEASE PRINT) Parent/Guardian s Signature Date Revs d 7/2017

17 Stepping Stones School 19 Harrison Avenue Roseland, NJ Fax SCHOOL NURSE CALENDAR SCHOOL YEAR 6/2017: packets for upcoming sent home to all parents in student backpacks. 7/5/2017: First day of ESY; completed student packets/in-school student medications (if needed) due back to school nurse for start of 2017 ESY program and new school year. 8/15/17: last day of ESY. 9/7/17: first day of school for students; please return completed student packets (required) and inschool medication/form (only if needed) to school nurse by today if not submitted during ESY. 9/2017: biannual student height/weight screenings and annual BP screenings completed this month. 12/31/17: documentation of receipt of flu vaccine is due to the school nurse for students 4 years 11 months of age or younger as of that date. If documentation is not received by this date state law requires exclusion of the student from school until the documentation is provided or until the end of flu season (3/31/2018). Please see the Influenza ad Pneumococcal Vaccine Information Form in the packet for more detailed information regarding this requirement. 1/2018 or 2/2018: annual in-school student immunization audit conducted by local Health Department 2/1/2018: School s Annual Status Report for immunization compliance submitted to NJ Dept. of Health 3/2018: biannual student height/weight screenings completed this month 3/31/2018: end date for flu season per NJ Dept. of Health guidelines; flu vaccine not required for preschool aged students after today. Ongoing/Monthly events: Monthly Health education classes: in Shabana and Christine s classes Ongoing updates from parents re: new immunizations (please provide updated list when your child receives any new vaccine), checkups/exams, vision/hearing checkups, medical test results, surgeries/procedures, specialist consults, etc. (written reports always helpful &welcome!!), forms for in school medications, medical excuse notes. Ongoing updates to parents re: information on seasonal and/or school related health issues. Any questions please contact the Health Office by dialing the main number and pressing option 6.

18 Stepping Stones School 19 Harrison Avenue Roseland, NJ (862) School Year Dear Parents: Welcome to Stepping Stones school year. Attached you will find the documentation required by federal HIPAA regulations. Please complete, sign, and date the form and return to the Stepping Stones. The staff cannot, by law, discuss your child s progress or school program with anyone that is not listed on the Authorization for Disclosure of Health Information Form. Therefore, it is very important that your child s Child Study Team, district case manager and Pediatrician/primary care provider at a minimum are listed on this document. Additional specialists and outside therapists may be listed as you see fit. If you have any questions about the HIPAA form please feel free to contact our health office. Sincerely, cc: M. Leiken Beth Patterson, RN School Nurse

19 The Arc of Essex County Authorization for Disclosure of Health Information (HIPAA) Individual s Date of Birth: I understand that the above named individual is using the services provided by The Arc of Essex County and The Arc of Essex County may require information from other agencies, providers, school districts or individual s in order to provide services. I also consent for The Arc of Essex County and the following designated agencies, school districts or individuals to disclose and communicate to one another information and records in their possession which relate to services and or treatment provided for the above named individual: Address: Address: Address: Address: Address: Address: Address: Address: My consent includes both verbal and written communication, which may include day-to-day observations of the following items (please initial beside each item you consent for): Medical and physical health records (excluding psychotherapy notes) Behavioral Health and Psychiatric records (excluding psychotherapy notes) Evaluation, assessment, and/or treatment information including occupational, physical, and/or speech therapies, audiological testing, etc. Evaluation materials including results of psychiatric evaluation, social work contact, psychological testing, medical, evaluation, learning disabilities consultation, and education classification report. Report of classroom and academic an/or vocational progress includes adjustments to teachers, peers, and general routines School records Other: Authorization for Disclosure 4/03 *Individual is defined as the participant in The Arc of Essex County Services

20 I understand I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance on this authorization. The request to revoke this authorization must be provided to the Chief Executive Officer at 123 Naylon Ave., Livingston, NJ The revocation will be effective the date the Chief Executive officer receives it. I understand that I may refuse to sign this authorization. However, refusal to sign may limit The Arc of Essex County s ability to obtain information required to assess the support needs and/or services. I also understand that I may inspect and/or copy any written information used or disclosed under this authorization. This authorization expires on or one (1) year from the date of the individual s or legal guardian s signature. Signature (or mark) of Individual or Legal Guardian Date Print Name of Legal Guardian (if applicable) If mark is provided in place of signature, the mark must be witnessed: Witness Signature Title Print Name of Witness Check here if names are listed on an additional sheet ( ) Authorization for Disclosure 4/03 *Individual is defined as the participant in The Arc of Essex County Services

21 New Jersey Department of Human Services Division of Developmental Disabilities Identifying Life Threatening Emergencies You must call in the event of a life-threatening emergency. Ask yourself: o Could this condition be potentially fatal? o Could the condition get worse and become life threatening if you drove the person to the hospital on your own? o Could moving the person on your own cause further injury? o Does the person require the skills/equipment of emergency medical personnel? Life-threatening emergencies may include: o Unconsciousness, unusual confusion/disorientation or losing consciousness o Difficulty breathing, not breathing, or breathing in a strange way o Having persistent chest pain, discomfort or pressure which persists for more than 3-5 minutes or that goes away and comes back o Severe bleeding from a body part o Broken bone that is showing through the skin or severe disfigurement of body part o Severe headache with slurred speech o Seizures that are not typical or back-to-back (3 in a row) o Seizures lasting longer than 5 minutes o Seizure resulting in serious injury; seizure in someone who is pregnant; seizure in someone who is diabetic; seizure in someone for the first time o Serious injury to head, neck or back Call first before your supervisor in a life-threatening emergency. If you are unsure whether a situation is a life-threatening emergency, call If the situation is not life-threatening, call your supervisor and provide appropriate care, including obtaining medical attention.

22 Stepping Stones School 19 Harrison Ave. Roseland, NJ (862) Fax (862) Danielle s Law Illness/Injury Policy: School Year We would like to inform you of our policy regarding children who become sick while at school or who sustain an injury. If your child should become sick or if your child is injured the staff will ensure proper care is provided. The school nurse will call you whenever your child is sick or injured. The school nurse will check your child and determine if he or she is able to stay in school or if he or she needs to be picked up. If it is determined that your child is showing signs or symptoms of a life-threatening emergency the staff is compelled by law to call for emergency services so that prompt medical care can be provided to your child. As per Danielle s Law that was passed in April 2004, facilities that provide care to persons have developmental disabilities MUST call 911 in the event a person is showing signs or symptoms of a life-threatening emergency. If your child should need emergency care a staff member from Stepping Stones School will accompany your child to the hospital. The parent or guardian will be notified directly following the 911 call. A copy of Danielle s Law and a fact sheet from the NJ Dept. of Human Services is attached for your information. As always, please inform the school if you have any changes to your telephone number or the emergency contact person for your child so that we can contact you in the event of an emergency. Stepping Stones School is committed to providing a safe environment for all of the children we serve Danielle s Law requires that staff serving individuals with developmental disabilities call 911 in the event of a medical emergency. Danielle s law became effective April 23, Violation of the responsibility to make a 911 call can result in staff losing their jobs, health care professionals may lose their licenses and be required to pay a large monetary fine. Definitions of a life-threatening and/or medical emergency can be found within the attached packet under Danielle s Law facts. Please sign below stating that you have read and understand the policy regarding Danielle s Law. Parent/Guardian Signature: Child s Name (please print): Date: