Northern Hills Training Center : : Spearfish, South Dakota

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Application for Services

IDENTIFYING INFORMATION

Name:
Address:
(Street)
(City)
(State)
(Zip)
Home Phone:
E‐Mail:
Sex:	Male Female
Birthday (month/day/year)
Birth Place:
Weight::	lbs.
Height:
Hair Color:
Eye Color:
Identifying marks or features
Developmental disability (or disabilities)
Date when disability began:
Social Security Number:
What benefits does applicant receive:	Social Security SSI Other
Is there a Representative Payee?	Yes: No
Medicare Number:
Medicaid Number:
Medicare Part D prescription drug plan & number:
Does applicant have other life or health insurance?	Yes No
If so please lis:
Legal Competency Status?	Adult/independent Incapacitated Incompetent Protected person
Guardian's Name:
(If there is a Guardian, where can we obtain a copy of the Letters of Guardianship

FAMILY INFORMATION

Father's name:
Address:
(Street)
(City)
(State)
(Zip)
Home Phone:
Mother's name:
Address:
(Street)
(City)
(State)
(Zip)
Home Phone:
Primary Contact Person:

EDUCATION, ASSESSMENT, EMPLOYMENT HISTORY

Schools (or programs) Attended	When	Where

Jobs (or Vocational Training)	When	Where

Medical, Psychological, Vocational Assessments	When	Where

Physician:
Date of last medical exam:
Medications and Dosages:
Allergies
Dentist:
Eye Doctor:
A copy of the following items will be helpful: Social Security card Medicare card Social Security benefit award letter Picture I.D. Immunization record Medication history Birth certificate Medicaid card Bank statement Guardianship Papers Psychological evaluation (if under 21) IEP & 3 year evaluation
Signature of Person Completing this application:

RELEASE OF CONFIDENTIAL INFORMATION

This release pertains solely to:
I,	, or
	(Guardian, if applicable)

HEREBY authorize the release of necessary confidential information including the findings of physical and psychological examinations, educational, clinical, laboratory and hospital records to the Northern Hills Training Center.

I also authorize and understand that income earned by me from all sources will be reported to various governmental agencies that request it. These agencies in turn, are assumed to keep the information confidential.

I also authorize this facility to transmit such information to a Physician, Psychologist, or to a co-operating State or Federal Agency, if requested.

This release will be applicable for one year from the date signed, unless otherwise stated. A photocopy of the signature is as valid as the original signature.

(Signature of Applicant)

(Signature of Guardian, if applicable)

(Signature of Witness, if signed by mark above)

These agreements pertain to:

ENROLLMENT AGREEMENT
If enrolled at NHTC, I agree to abide by the rules and regulations of the Training Center. I will not terminate my enrollment without prior discussion with an official of the Training Center. I agree to notify officials at the Center at least two weeks prior to leaving the program for any reason, including vacations, except for extreme emergencies.

MEDICAL TREATMENT
I HEREBY authorize the staff of the Training Center to initiate any planned, scheduled, or emergency procedures that may be necessary to insure my health and well being. I hereby authorize staff and Physicians at Regional Hospital to provide services as necessary or as arranged by staff of the Training Center.

PROCEDURE FOR GRIEVANCES AND DISPUTES
If you disagree with a decision by any staff that directly affects you, please let us know. We can help resolve misunderstandings or incorrect decisions if you will let that staff member's immediate supervisor or your Case Manager know. If your concern relates to a decision by NHTC that you are not eligible for services, you may ask the SD Department of Human Services to review this decision.

PHOTOGRAPH RELEASE FORM
I HEREBY authorize permission for me to be photographed, filmed, videotaped, and involved with other general media during enrollment at the Training Center. I understand that the pictures may be used for the purposes of reproduction, publication, and illustration in all Media deemed appropriate by the Center.

RELEASE OF RESPONSIBILITY
I HEREBY give consent to the Training Center to transport me on any planned and supervised extra-curricular activities such as bowling, swimming, games, parties, field trips, etc., sponsored by the Training Center. I understand that transportation will be provided in insured vehicles. I exonerate Northern Hills Training Center from any damages that I might cause to any person(s) or property while in their charge. I further understand that I may be excluded at any time if it is judged that my behavior is detrimental to the purpose and functioning of these activities.

CONDITIONS OF RELEASES and SIGNATURE(S)
*This release will be applicable for one year from the date signed, unless otherwise noted.
*A photocopy of the signature is as valid as the original signature.
*I have read and/or I understand through discussion the full meaning of these releases.

(Signature of Applicant)

(Signature of Guardian, if applicable)

(Signature of Witness, if signed by mark above)

THANK YOU AGAIN FOR YOUR INTEREST IN NORTHERN HILLS TRAINING CENTER.

Northern Hills Training Center : : 625 Harvard Street : : Spearfish, SD 57783 : : Telephone: 605-642-2785 : : click here to email us

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