DS9 Document EFTA00794310

To • • NYS, 7tisyl 12evi a YO4C-Z (arm rod itc z e corn) Ny. I/1)111;4mi av-b&Y" C obarlier-O 1t\e- woricis pi j041-to (Pr> Re= 4c,c Cinch,Ls coves, 1414e,,, ana Ket4)vini 61,0 CM,(11Crarskl (TN ykdat" -uty-tair I eel r-Yb YY1, e 7,-C6-prn on of io 91?-o) , EFTA00794310 January 4, 2019 Mrs. Ann Rodriguez 6014 Estate Smith Bay Saint Thomas, Virgin Islands 00802 Dear Mrs. Rodriguez: Piney 7Woods School Congratulations! We are excited to inform you that your daughter, Sierra T. Poleon, has been accepted to The Piney Woods School, on a Conditional /Probationary Status, for the 2018-2019 school year as a Freshman, starting in the Spring 2019 Semester (January 2019). (In your daughter's case, "Conditional / Probationary Acceptance" refers to her ability to maintain successful academic progress and demonstrate acceptable social and behavioral skills while attending The Piney Woods School.) In order for your daughter to complete the registration process, the enclosed forms, along with the requested documents indicated below are needed. Please submit the required documents, on or before January 7, 2019. Failure to submit this information, may result in the loss of your child's slot or withdrawal of their acceptance. We must receive the following documents in order to complete the registration proceed: it I . Medical Consent Form (enclosed, must be notarized) Leave Authorization Form (enclosed, must be notarized) Student Health History (enclosed, must be completed by a physician) Application Fee ($50.00) — Non-Refundable The above referenced documents must be mailed to: The Piney Woods School Office of Admissions Post Office Box 99 Piney Woods, MS 39148 Attention: Mr. William Barber ic We ome to the Piney Woods Family! Should you have any questions, please feel free to call us at 601- 84 -2214, ext. 3327. an odge Interim Director fir Admissions/Enrollment Chief Advancement Officer 5096 Highway 49 South • Piney Woods, MS 39148 Academics — Box 100 • Administration — Box 99 Institutional Advancement — Box 57 • Operations — Box 57 Physical Plant — Box 57 • Student Support Services — Box 100 TEL: (601) 845.2214 • WEB: www.pineywoods.org EFTA00794311 thansosenod THE INEY OODS SCHOOL 01IILI O/4ff 0 ,101Mer AT A Take IMO. 1 O O 'foams MED2CAI CONSENT FORA' 't au loo • Piney Woods, MS 39148 bill (601) 84 - 14, ext. 2223 • fax (601) 84.5 - 4909 or (601) 145 - 6977 In consideration of the agreement by The Piney Woods School to admit as a student (social security number: ), the undersigned parent/guardian hereby authorizes The Piney Woods School and its agent and employees to secure for the above-named student any medical, mental health, or dental treatment which they, in their sole judgment, may deem necessary and proper for said student. We further specifically authorize The Piney Woods School and its agents and employees to execute administration of any medical, mental, or dental treatment or procedure whatsoever to said student. We also authorize Century Life Insurance Company (or any successor company) to pay directly to The Piney Woods School all benefits that become payable. We herby release and waive any claims for damages which we or the said student might have against The Piney Woods School or its agents or employees in any manner arising from or in the course of medical, mental health, or dental treatment or procedure administered to said student. We, individually and on behalf of the student, do hereby release, acquit, and forever waive and discharge the said Piney Woods School Century Life Insurance Company (or any successor company) and their agents and employees from any and all action claims for compensation on account of personal it juries from instances occurring while the student is enrolled at The Piney Woods School. We will take sole responsibility for any bills incurred which are not covered by insurance. This form also authorizes the release of information pertinent to the treatment of this child. I AUTHORIZE any doctor, medical practitioner, hospital, clinic, other medical or medically related facility or insurance company, the Medical Information Bureau, Inc., consumer reporting agency or employer, having information available regarding either: (a) benefits for which either I, or the minor child for whom I am either parent or guardian, may be entitled to from this claim, or (b) the diagnosis, treatment and prognosis with respect to any physical or mental condition and/or treatment of me or the minor child for whom I am the parent or guardian; to give to Century L(fe Insurance Company, or its legal representatives, any and all such information. I AGREE that a photographic copy of this Authorization will be valid as the original. Parent/Guardian: Insurance Carrier: Address: Address: City/State/Zip: City/State/Zip: Home #: Policy/Medicaid: Work #: Claim Service #: Cell #: WITNESS our signatures this the day of , 20 Signature of Parent/Guardian Signature of Student Subscribed and sworn before me this day of , 20 in County and the State of Notary Public (SEAL) My Commission Expires EFTA00794312 HE PINEY OFFICE OF ADMISSIONS WOODS P. O. Box 100 • Piney Woods, MS 39148 • tel (801) 845-22140 fax (801) 845-4909 or 801.845-8W SCHOOL tsseneso no no% a.. Ott stanirmakis. CELEORATING OVER POO YEARS Student Parentilegal Guardian* HOMO ACORNS Telephone( * If both parents/guardians are authorized I pickup, please be sure to list both names Date of Birth Grade home work ( ) E-Mail Address cell Authorization To Attend Events and Participate in Media Activities f.s parent/legal guardian of the above student, I hereby grant permission to The Piney Woods School for my child to: 1 Attend the following events, on or off campus, sponsored by The Piney Woods School: field Dips (class, athletic events, special events. concerts, plays, state fairs, park events, etc.). 2. Appear in or on the following medium: brochures, videos, newsletters, radio talk shows, television ads, etc.. all of which are used to promote the school. I understand that such promotions will be in keeping with the mission and educational philosophy of The Piney Woods School, and that The Piney Woods School reserves the right to utilize such material in current and future promotional projects. Phone return this entire loan to: The Piney Woods School Office of Admissions PO. Box 100 Piney Woods, MS 39148 Parent / Guardian Signature Leave Authorization Form In order to insure the safety of our students in regard to leaving campus to travel home or elsewhere, we are asking you to complete the following form, in it's entirety, indicating those individuals authorized to check out your child. If you would like to change or add any names at a later date, you must co ate a Change of Authorization Form (which has to be mailed to you). Please Include the complete name, complete address, and telephone number of each person authorized to pick up your child (no additional sheets may be used). 1. 5. RELATIONSHIP TO STUDENT RELAOCNSLIN TO STUDENT 2. RELATIONSHIP TO STUDENT 6. RELATIONSHIP TO STUOENT 3. RE,Ar.ONSessr TO STUDENT 7 MAN/NSW TO STUDENT 4 RELATIONSHIP TO STUDENT 8. PILLAININIIME TO STUDENT Sworn to and subscribed before me this day of 2018, in the county of and the state of My Commissor Expires Notary EFTA00794313 HE PINEY WOODS SCHOOL thirghlens %tad OneSisseentrainur STUDENT HEALTH HISTORY Highway 49 South • P. 0. Box 69 • Piney Woods, MS 39148 tel 601.845.2214 • fax 601.845.0287 Student's Last Name First Media Grade Home Address Male Female Post Office Box City (Area/Country Code) Telephone Number State Zip 1. How is health care provided for this student? _employment Insurance _private insurance _social security insurance Medicaid Other 2. With whom does this student live? I t r HE' mHt F T[ pH , N 3. Does this student have any of the following health conditions: asthma diabetes _ADHD _vision heart hearing allergies anemia _seizures/conwlsions Explain all checked: 4. Does any close relative of this student have a history of (ch.* and indicate reirellerild to tee student: _diabetes anemia epilepsy cancer heart disease _high blood pressure Make cell anemia _other 5. WEIGHT HEIGHT PULSE BLOOD PRESSURE 6. SKIN EVE EAR NOSE THROAT TEETH NECK LUNGS HEART CHEST 7. TB SKIN TEST (required) 8. Description of abnormal findings. 9. Special instructions or special limitations: I certify that I have examined this student and he/she may compete in supervised school athletic activities. Type or print physician's name Physician's signature Address Cray State ZIP Date Telephone • ) (J MPH Pro,,N Does your child take medication? _yes _no If yes, list medication(s): Parent / Guardian Signature Exam Date EFTA00794314