SETTLEMENT AGREEMENT BETWEEN

THE UNITED STATES OF AMERICA

AND

PINE HILLS KIDDIE GARDEN,

FORT WAYNE, INDIANA

DJ#: 202-26-62


Settlement Agreement | Department of Justice Press Release



I.BACKGROUND AND PARTIES

  1. The parties to this Settlement Agreement ("Agreement") are the United States of America and Pine Hills Kiddie Garden ("Pine Hills"), located in Fort Wayne, Indiana.
  2. This matter was initiated by a complaint filed with the United States Department of Justice (the "United States") against Pine Hills, D.J. No. 202-26-62, alleging violations of title III of the Americans with Disabilities Act of 1990 ("ADA"), 42 U.S.C. 1218112189, and its implementing regulation, 28 C.F.R. Part 36.
  3. In the complaint, Mr. David Nugent, a parent of a six-year-old daughter with Type I diabetes, alleged that Pine Hills refused in 2007 to permit the daughter to participate in field trips as part of the summer program, unless she is accompanied by a parent or a medically trained person hired by the parent. Pine Hills admits that it initially provided Mr. Nugent with a letter containing those options but that, later, after discussion, provided other alternatives. Pine Hills submits that Mr. Nugent ended the negotiations, and that the issue with Mr. Nugent was more related to a peanut allergy issue than a diabetic issue. Pine Hills further submits that it has and continues to make a practice of many of the guidelines outline in this Settlement Agreement, and welcomes the additional policies suggested by the Department.
  4. The United States is authorized to investigate alleged violations of title III of the ADA, and to bring a civil action in federal court if the Department is unable to secure voluntary compliance in any case that involves a pattern or practice of discrimination or that raises issues of general public importance. 42 U.S.C. § 12188(b).
  5. Pine Hills is a place of public accommodation covered by title III of the ADA. 42 U.S.C. § 12181(7)(I)-(L); 28 C.F.R. § 36.104.
  6. The ADA prohibits public accommodations, including summer camps, from discriminating against an individual on the basis of disability in the full and equal enjoyment of its goods and services. 42 U.S.C. § 12182(a). Ensuring that private day care centers do not discriminate against persons with diabetes is an issue of general public importance.
  7. In consideration of the terms of this Settlement Agreement, and in particular the provisions in Sections II-III, the Attorney General of the United States agrees to refrain from undertaking further action in this case, except as provided in Section V(D).
  8. The parties agree to resolve this matter as set forth below.

II.TERMS OF AGREEMENT

  1. Pine Hills agrees not to discriminate against any child on the basis of diabetes; that is, Pine Hills agrees to provide all children with diabetes with an equal opportunity to attend Pine Hills and to participate in all programs, services, or activities provided by Pine Hills. Pine Hills will not refuse to admit any child to any of its sessions or programs because the child has diabetes or requires diabetes care unless Pine Hills concludes that the child poses a "direct threat" as defined by 28 C.F.R. § 36.208, and/or the child's participation would result in a "fundamental alteration" of the program, service or activity as defined by 28 C.F.R. § 36.302.
  2. Pine Hills agrees to evaluate, on a case by case basis, and make reasonable accommodations, for children with diabetes. Accommodations include, but are not limited to, supervising and monitoring of children with diabetes while using blood glucose monitoring tests, insulin pumps, syringes, or other diabetes related medical equipment or consumption of food while participating in any program, service, or activity, whether on Pine Hills' premises or elsewhere while attending Pine Hills.
  3. Pine Hills will take necessary steps to ensure that a child's diabetes care is integrated into the usual routine at Pine Hills and its programs to the greatest extent possible in accordance with the ADA.
  4. Pine Hills has adopted the policy, entitled "Pine Hills Kiddie Garden Policy on Diabetes Management" ("Policy"), which is attached hereto as Appendix A and is incorporated herein by reference. Pine Hills will print and maintain copies of the Policy in a central location, provide the policy to any interested party requesting it, and will incorporate the policy into its standard operating policies in accordance with applicable state and local law and the ADA.
  5. Pine Hills will provide training as set forth in the Policy.
  6. When informed that a child who has applied to Pine Hills or its programs has diabetes, Pine Hills will:
    1. Advise the child's parents, guardians, or caretakers of the Policy on Diabetes Management (attached hereto as Appendix A), and advise that Pine Hills will comply with all applicable federal, state, and local laws;
    2. No less than two weeks prior to the first day of any session or program, or less if a family is applying for a program that begins in less than two weeks and Pine Hills can accommodate the request, the child's parents shall provide Pine Hills with the following:
      1. Completed Medical Management Plan, an example of which is attached as Appendix B, clearly detailing any and all necessary care for the child's medical management and signed by the child's primary care physician or endocrinologist;
      2. Completed Physical Exam Form, Appendix C attached hereto, and any other clear, typewritten health-related documents deemed relevant by the child's primary care physician or endocrinologist;
      3. Information regarding all equipment, food, and substances to be provided by the child's parents/guardians that are not regularly provided by Pine Hills and that are necessary to meet or comply with the child's Medical Management Plan; the Physical Exam Form; the Policy; and any health related documents as noted in the preceding subparagraph (ii);
      4. Written permission to undertake steps indicated on the child's Medical Management Plan (provided by the child's parents or guardians) and permission to respond to any diabetes-related or other emergency in a manner consistent with those instructions or emergency protocols;
      5. Executed general release and waiver of liability for care in a form required of all children as a prerequisite to attendance that is substantially similar to Appendix D, attached hereto. This document releases Pine Hills and their agents from liability stemming from any action relating to the care of any child.
      6. Information regarding containers for proper disposal and maintenance of all materials including, but not limited to, keeping the child's blood glucose meter and insulin pump in good working order (including, but not limited to, cleaning and performing controlled testing per the manufacturer's instructions); and
      7. Reasonable availability of parents, guardians or their designees to attend meetings the first day of a session or program and to be available in conformance with the Policy.
    3. Communicate with parents or guardians as set forth in the Policy and Medical Management Plan about the child's diabetes management, diabetes care, or diabetic health-related concerns;
    4. Encourage compliance with the Medical Management Plan and Policy, independence, and self-care consistent with the child's ability, skill, maturity, and development level; and
    5. Respect the child's and his or her family members' rights to confidentiality and privacy consistent with all pertinent local, state, or federal laws, regulations, or requirements.
  7. Pine Hills will arrange for a certified diabetes educator to provide basic training to the appropriate personnel at Pine Hills. That basic training will include a general overview of diabetes and typical health care needs of individuals with diabetes, recognition of common symptoms of hypoglycemia and hyperglycemia, and ways to get help quickly. The person assigned to do the training will also provide assistance to, and respond to inquiries from, parents about any matter or concern related to the care or treatment for a child with diabetes.
  8. Pine Hills will maintain a record at its office of all such admission inquiries on behalf of children with diabetes, including insulin-dependent diabetes, and the disposition of such inquiries for a period of three years from the date of the inquiry.
  9. Nothing in this Agreement is intended to cause Pine Hills to violate any provision of any state or local law. None of the Parties to this Agreement are aware of any state, local and/or municipal law in Indiana that prevents Pine Hills from enrolling and caring for children as provided in this Agreement. Should there be any reason to believe there is such a conflict, the Parties agree to meet to resolve or negotiate terms to address any alleged conflict. The United States and Pine Hills will consult on changes proposed to the Policy at least twenty (20) business days before any policy incorporated by reference herein is amended.
  10. Retaliation and Coercion. Pine Hills will not retaliate against or coerce in any way any person who is trying to exercise his or her rights under this Agreement or the ADA.

III.MONETARY RELIEF FOR COMPLAINANTS

  1. The ADA authorizes the Attorney General to seek a court award of compensatory damages on behalf of individuals aggrieved as the result of violations of the ADA. 42 U.S.C. § 12188(b)(2)(B); 28 C.F.R. § 36.504(a)(2). Within thirty (30) days of the effective date of this Agreement, Pine Hills agrees to pay David, Amy, and Allyson Nugent ("Nugents") $10,000.00 in damages and to send a copy of this Agreement and Appendixes E and F, hereto attached, to the Nugents by certified mail, return receipt requested, or by Federal Express. The Nugents must return an executed "Release of All Claims," Appendix E, to Pine Hills within thirty (30) days of receipt of said documents. Pine Hills will send the undersigned counsel for the United States a copy of Appendixes E and F when they are sent to the Nugents.
  2. If the Nugents accept Pine Hills's offer of relief as set out in Appendixes E and F, Pine Hills will, within thirty (30) days of receipt of the signed "Release of All Claims," send the Nugents, by certified mail, return receipt requested, or by Federal Express, a check for TEN THOUSAND DOLLARS ($10,000.00). Pine Hills will provide to the United States a copy of the check and transmittal letter sent to the Nugents.

IV.CIVIL PENALTIES.

Pine Hills agrees to pay to the United States the sum of TEN THOUSAND DOLLARS ($10,000.00 in civil penalties pursuant to 42 U.S.C. § 12188(b)(2)(C)(i), by delivering a check in that amount made payable to the United States Treasury. The check of TEN THOUSAND DOLLARS ($10,000.00) shall be provided to the United States no later than thirty (30) days prior to the expiration of this Agreement.

V.ENFORCEMENT AND IMPLEMENTATION

  1. Compliance Reports. Pine Hills will provide written reports to the United States regarding compliance with this Agreement. The first, second, and third reports shall be due six (6), eighteen (18) and thirty (30) months, respectively, from the entry of the Agreement. Each of the three reports must state the number of applicants with diabetes who applied to attend any program, the particular diabetes care requested for such applicant, the procedure followed to determine whether to admit such applicant to the program, any reason admission to the program was denied, and if an applicant was admitted, what diabetes care was agreed upon. Pine Hills will maintain records to document all statements in the report. Pine Hills shall also submit detailed information about any complaints to Pine Hills by children with diabetes or their parents or guardians, or actions taken by Pine Hills that involve any child who has diabetes, including any decision to deny a child's request for an accommodation after admission to Pine Hills or any request or other action by Pine Hills that contributes to a child's removal or departure before the end of a session for which the child was enrolled.
  2. Complaints. During the term of this Agreement, Pine Hills will notify the United States if any individual brings any lawsuit, complaint, charge, or grievance alleging that Pine Hills discriminated against them on the basis of disability. Such notification must be provided in writing via certified mail within fifteen (15) days of when Pine Hills has received notice of the allegation and will include at a minimum, the nature of the allegation, the name of the individual bringing the allegation, and any documentation possessed by Pine Hills relevant to the allegation.
  3. Notices. All notices, reports, or other such documents required by this Agreement shall be sent to the Parties by fax and by delivery via Federal Express to the following addresses or to such other person as the parties may designate in writing in the future:
  4. For notices to the United States:

    John L. Wodatch, Chief
    Attention: Robert Mather
    Disability Rights Section
    Civil Rights Division
    U.S. Department of Justice
    1425 New York Avenue, NW
    Washington, D.C. 20005
    (202) 307-2236 (telephone)
    (202) 616-6862 (facsimile)

    For notices to Pine Hills:

    Nelson and Beverly Eagle
    5755 South Depew Circle
    Littleton, Colorado 80123
    (303) 932-7682 (telephone)
    (303) 932-8398 (facsimile)

  5. Enforcement of Agreement. The United States may review compliance with this Agreement at any time and may enforce this Agreement if the United States believes that any requirement therein has been violated. If the United States believes that this Agreement or any portion of it has been violated, it will specifically notify Pine Hills' Chief Executive Officer in writing and it will attempt to resolve the issue or issues in good faith. The United States will give Pine Hills thirty (30) days from the date it notifies Pine Hills of any breach of this Agreement to cure that breach, prior to instituting any court action. If the United States is unable to reach a satisfactory resolution of the issue or issues raised within 30 days of the date it provides notice to Pine Hills, it may institute a civil action in federal district court to enforce the terms of this Agreement or title III and may, in such action, seek any relief available under the law. Failure by the United States to enforce any provision or deadline of this Agreement will not be construed as a waiver of its right to enforce other provisions or deadlines of this Agreement.
  6. Term of the Agreement. The Agreement shall become effective as of the date of the last signature below and shall remain in effect for three years from that date.
  7. Entire Agreement. This Agreement, and any appendixes attached, constitute the entire agreement between the parties on the matters raised herein, and no other statement, promise, or agreement, either written or oral, made by any of the parties or agents of any of the parties, that is not contained in this written Agreement or attachments, shall be enforceable regarding the matters raised herein.
  8. Copies Available. A copy of this Agreement will be made available by the United States or Pine Hills to any person upon request.
  9. This Agreement fully and finally resolves any and all of the allegations of the complainants and the United States in this case. It does not purport to remedy other potential violations of the ADA by Pine Hills.
  10. Binding Effect. This Agreement shall be binding on Pine Hills, its agents and employees. In the event Pine Hills seeks to transfer or assign all or part of its interest in any facility covered by this Agreement, and the successor or assign intends on carrying on the same or similar use of the facility, as a condition of sale Pine Hills shall obtain the written accession of the successor or assign to any obligations remaining under this Agreement for the remaining term of this Agreement.
  11. Non-waiver. Failure by the United States to seek enforcement of this Agreement pursuant to its terms with respect to any instance or provision will not be construed as a waiver to such enforcement with regard to other instances or provisions.
  12. Signatory. A signatory to this document in a representative capacity for Pine Hills represents that he or she is authorized to bind that party to this Agreement.

 

FOR PINE HILLS KIDDIE GARDEN: FOR THE UNITED STATES OF AMERICA

 

_____________________________
NELSON AND BEVERLY EAGLE
Owners
5755 South Depew Circle Littleton,
Colorado 80123

 

THOMAS E. PEREZ
Assistant Attorney General
Civil Rights Division

JOHN L. WODATCH, Chief
PHILIP L. BREEN, Special Legal Counsel
RENEE M. WOHLENHAUS, Deputy Chief
Disability Rights Section
Civil Rights Division

__________________________
ROBERT J. MATHER,
Trial Attorney
Disability Rights Section
Civil Rights Division
U.S. Department of Justice
Washington, DC 20530
Telephone: (202) 307-2236
Fax: (202) 616-6862 robert.mather@usdoj.gov

 

Dated: Dated:             October 19,2009            

 

 

Attachments

 

 

APPENDIX A

Pine Hills Kiddie Garden
Policy on Diabetes Management

Pine Hills Kiddie Garden ("Pine Hills") is committed to complying fully with the Americans with Disabilities Act ("ADA") and any other applicable laws and regulations pertaining to children with disabilities.

Children with diabetes Type I or Type II who attend Pine Hills may require assistance with diabetes management.  The management regime of every child with diabetes may be different and, for this reason, it is the view of Pine Hills that one Policy cannot dictate the particular protocol followed by Pine Hills for all individuals.  Pine Hills will make an individual assessment of the special needs of each child with diabetes on a case-by-case basis and will work with families to provide reasonable accommodations to children with diabetes in accordance with applicable laws.  Successful participation and accommodation of the children depends on an actively cooperative relationship and ongoing communication between the parents or guardians of the children and Pine Hills. 

Parents or guardians who wish to enroll a prospective child with diabetes should submit a complete application for the child at least one month ahead of the scheduled start date for daycare, camp, or other activity or two weeks for daily events such as field trips, to permit adequate time for the staff to meet with the parents or guardians of the child to examine the individual needs of the child on a case-by-case basis and to take appropriate steps to comply with pertinent laws. 

Within two weeks of the child's admission to a particular session or program, Pine Hills will send to the parents or guardians a copy of this Policy, a Diabetes Management Plan Form, and a Physical Examination Form.  A reasonable time (i.e., twenty (20) business days) prior to the beginning of any session or program, the parents or guardians of a child with diabetes will send the Director at Pine Hills a completed Diabetes Management Plan Form, typewritten in easy to understand terms, detailing care necessary for the child's safety; a completed Physical Exam Form; and a signed general release, if the same release is  required of all other children regardless of disability. 

For current children who should require treatment for diabetes for the first time during any session, parents or guardians of these children should immediately notify Pine Hills, submit the completed Management Plan Form as set forth above, and comply with the remaining aspects of this Policy with sufficient time to allow Pine Hills to make good faith efforts for continuation of the session consistent with this Policy. 

Because each child's care is different and the activity levels of each child may be different, this policy should not be construed to prevent Pine Hills from working with health care professionals and the child's guardians or parents in an effort to expedite the child's admission or improve the child's experience.

Parents or guardians will be available at Pine Hills's request to attend and participate on the first day of a session with the child and, if deemed necessary by either party, to attend a prior run through of the first day, and to continue to meet with and advise the staff working with the child about proper diabetes care.  Parents will be available by phone or have other emergency contacts (which may include the child's health care provider) available by phone each day that the child is participating in a session to answer questions from Pine Hills or the child regarding the child's management of diabetes care and to approve particular actions related to proper care when necessary.

Parents or guardians will provide specific information and training about the child's diabetes and particular needs related to diabetes care to Pine Hills, and will permit the child's personal health care providers to share information with Pine Hills staff and other health care personnel when necessary to assure the child's safety and compliance with the child's Diabetes Management Plan.  The information should include all equipment, food, and substances to be provided by the parents/guardians that are not regularly provided by Pine Hills; and containers for proper disposal and maintenance of all materials including, but not limited to, keeping the child's blood glucose meter and insulin pump in good working order. 

Parents or guardians will promptly inform Pine Hills of relevant changes in the child's health status.  The parents or guardians will provide, along with instructions about proper maintenance or use of all items, all supplies and equipment necessary for the child's safe participation in all activities.

Parents or guardians will provide and properly maintain all supplies and equipment for the child's diabetes and assist with proper disposal of equipment and supplies.  Parents or guardians will provide written permission to undertake the steps indicated on the child's Diabetes Management Plan and Physical Exam Form, and will provide all applicable releases in writing two weeks before a child joins any session or program at Pine Hills.

Training of Personnel

In accordance with applicable law, including those regulations enforced by the applicable Department of Public Health, if a child with diabetes applies for any session or program, Pine Hills will arrange for a qualified health care professional to provide basic training to the appropriate personnel at Pine Hills.  That basic training will include a general overview of diabetes and typical health care needs of individuals with disabilities, recognition of common symptoms of hypoglycemia and hyperglycemia, and ways to get help quickly.  The person

assigned to do the training will also provide assistance and respond to inquiries from parents about any matter or concern related to the care or treatment for a child with diabetes.

Primary teachers and any other teacher or staff member who has primary responsibility for a child with diabetes for more than 60 minutes in any one day will have received training that enables Pine Hills to provide all care required to comply with applicable law.  Such training includes (but may not be limited to) an overview of diabetes, general information on how to recognize signs and symptoms of hypoglycemia and hyperglycemia, diabetic care practices related to glucose monitoring and regulating glucagon and insulin administration, including by insulin pump.  In addition, depending on the unique needs of the child, training may include information about dietary requirements for individuals with diabetes in general and particular information about dietary requirements for particular children, and training and guidance from parents or guardians of children about any reasonable accommodations needed by a child as identified in each child's Diabetes Management Plan (which is to be provided by the parent or guardian to Pine Hills at least twenty (20) business days prior to any session) and related documents.  Parents or guardians must provide information and training necessary for staff to be trained with regard to any unique needs of their child.

Monitoring Blood Sugar Levels

Parents or guardians will check the child's blood sugar levels each morning before the child arrives at Pine Hills to ensure they are within the established "target range" in the child's diabetes Medical Management Plan.  Parents or guardians agree to be available to be contacted as deemed necessary to provide information, assistance, or guidance so that Pine Hills satisfies each child's Diabetes Management Plan.  If the child self-identifies, or staff recognizes symptoms of hyperglycemia or hypoglycemia, the staff will assist the child to check blood sugar and treat the symptoms.  Pine Hills will assess the level of assistance or supervision that is reasonable depending on the individual needs of the child in the particular situation and provide whatever assistance is appropriate in the situation consistent with the Plan and applicable law.

Further, parents or guardians will furnish all appropriate meals and snacks that are not regularly provided by Pine Hills and that are necessary to meet the child's needs.  The parents or guardians will also ensure  that the carbohydrate content falls within the proper amounts set forth in the Diabetes Management Plan so that the totals will be predetermined and calculated by the parents.  Carbohydrate values will be calculated and provided on labels on each food item provided by the parents so that the staff may monitor the appropriate use of insulin and insulin pumps or other equipment to administer insulin. 

At the onset of any symptom of hyperglycemia or hypoglycemia, the child will notify the staff that the child needs to have a glucose test.   Should the staff or nurse notice any symptom(s) of hyperglycemia or hypoglycemia, the staff or nurse will take steps reasonably consistent with the Diabetes Management Plan.            

Insulin and Insulin Pumps

Children with diabetes are responsible for arriving at Pine Hills with all necessary supplies.  Children may carry their own medical supplies and snacks in a safe fashion that meets local code or safety standards for the care and disposal of medical supplies so that these supplies are in close proximity to the child.  To that end, children with insulin pumps are expected to come to Pine Hills with a fully functional pump, back-up insulin and syringes, and glucose tablets for low sugar episodes, and any other equipment necessary for that child.  When the child cannot hold these supplies, the supplies will be held at the administrative office, health office, or by a staff member.

Nothing in this process shall prevent Pine Hills from exercising its discretion for the benefit of the child.  This policy is not intended to provide fixed rules for dealing with all care involving diabetes; however, the policy sets a minimum standard for ADA compliance.  This policy is not intended to serve as a contract with any individual child.  The policy may be modified or updated at any time following prior approval by the Department of Justice during the pendency of the Agreement in the case identified below. Absent written notice from Pine Hills, no representative of Pine Hills, other than the Administrator, is authorized to make written or oral representations regarding the statements contained in this Policy.  Should you have any questions, the Administrator will be happy to answer your questions or help you get the information you need.



APPENDIX B


DIABETES MANAGEMENT PLAN
Dated:____________________

This plan should be completed by the child's personal health provider/physician and parents/guardian and immediately updated by these persons with any new information in the future.

Effective Dates                                                                                                           
Child's Name:                                                                                                
Date of Birth:                                                                                                             
Physical Condition (Identify and Explain): _______________________________
__________________________________________________________________
__________________________________________________________________
Date of Diagnosis:                                                                                                     
Grade: ____________________________________________________________

Contact Information:  Circle the primary contact person and phone number Mother/Guardian:                                                                                                       
Home Address:                                                                                                         
Employer:                                                                                                                   
Employer's Address: ________________________________________________
Telephone:  Home                                 Work:                                    Cell:               
Father/Guardian:                                                                                                        
Home Address:                                                                                                          
Employer:                                                                                                                   
Employer's Address: ________________________________________________
Telephone:  Home                     Work:                                    Cell:                           
Who has custody of the child? _________________________________________

Child's Doctor/Health Care Provider:
Name                                                                                                                          
Address                                                                                                                      
Telephone:                                                                                                                  
Emergency Number:                                                                                                  
Other Emergency Contacts:
Names:                                                                                                                       
Relationship:                                                                                                              
Telephone:  Home                     Work:                                    Cell:                           

Notify parents/guardian or emergency contact in the following situations:                
                                                                                                                                   
                                                                                                                                   
Recommended Monitoring of Child:                                                                              
                                                                                                                                          
                                                                                                                                          

Specify any medical time requirements: ____________________________________
___________________________________________________________________

Can child perform own monitoring?   ❑  Yes   ❑  No

Exceptions: _________________________________________________________
___________________________________________________________________             

Identify the type of any meter, monitor, nebulizer, applicator, needle, pump, or any other devices necessary for the child's Medical Management Plan (include model and instruction booklet):  
                                                                                                                                        
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

What signs does the child demonstrate when child is symptomatic?
__________________________________________________________________

Foods to avoid, if any ________________________________________________

Instructions for when food is provided to the child (e.g., as part of a party or food sampling event): ___________________________________________________________________

Exercise and Sports Limitations
List, identify, and explain any restrictions to exercise, sports, or any other activities:
____________________________________________________________________
____________________________________________________________________
                                                                                                                                        

Treatment Supplies to be kept at the School site and provided by parent/guardian are
as follows (please provide specific instructions regarding the storage and treatment of all supplies): _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

For children with medical concerns, please complete the supplemental form.

This Medical Management Plan has been approved by:                         

                                                                                                                                   
Child's Physician/Health Care Provider                      Date

I give permission to the school to perform and carry out the care tasks as outlined in the Medical Management Plan.  I also consent to the release of the information contained in this Medical Management Plan to all staff members and other adults who have custodial care of my child such as those persons on the emergency list and who may need to know this information to maintain my child's health and safety.  A written revocation or amendment to this document must be delivered to the school director by the child's Parent/Guardian in order to effectuate a revocation of the same.   The school reserves the right to request additional documentation after review of the within document.

Acknowledged and received by:                 

                                                                                                                                   
Child's Parent/Guardian                                              Date                                        

                                                                                                                                   
Child's Parent/Guardian                                              Date                                        

 

 

                                      

APPENDIX C

PHYSICAL EXAM FORM

To be completed and approved by the child's diabetes nurse educator, endocrinologist, or  primary care provider/physician.

Dear Diabetes Team:

Your cooperation in supplying the following information about an applicant for Pine Hills Kiddie Garden is greatly appreciated.  The child will not be accepted without your approval on this form.

To Parent/Guardian:  Please complete boxed information BEFORE submitting to Physician.

Name of applicant___________________________

Gender (circle one)  M      F

Date of Birth _______/_________ 

Address:____________________________________

Date of most recent exam: _____________________

I have read the Diabetes Management Plan, attached to this form, and certify that it provides an easy to understand, complete regime of care for this child's safety at Pine Hills Kiddie Garden, I recognize that the child will be active at this camp and represent that this plan accounts for applicable varying activity levels.

Have any complications of health or disabilities been detected?  Yes/No (circle one)
If yes, please specify:
________________________________________________________________________

Is the child emotionally and physically mature or responsible enough to independently manage his/her health concerns? Yes______; No_____.  If not, please explain the minimum level of medical licensure and training required for the child's safety (unless fully described in the Medical Management Plan): ______________________________

Do you have any specific concerns regarding the management of this child's health or health at school not fully described in the Medical Management Plan? Yes____, No____.
If yes, please explain:______________________________________________________

Do you recommend any limitation on child's activity while at camp beyond those described in the Medical Management Plan?  Yes _______ No ______ If yes, please describe:_______________________________________________________________

_______________________________________________________________________
I certify that the information above is correct to the best of my knowledge and agree to answer questions and provide management guidance to the camp at Pine Hills Kiddie Garden as requested by the school at the sole cost and expense of the parent/legal guardian of the child.

Primary Care Physician/Endocrinologist's Name (typed or printed)

_____________________________________________________________

Address:  _____________________________________________________

Phone:  (____)__________

Primary Care Physician/Endocrinologist's Signature:

_________________________________________________

 

Parents/Guardians name (typed or printed)

_________________________________________________

Address:  _______________________________________________________________

Phone:  (____)_________________

                                                           
Parents/Guardian Signature:
                       
Father:                       ____________________________

Mother:                      ____________________________

Legal Guardian:        ____________________________

       

    

 

APPENDIX D

RELEASE AND WAIVER OF LIABILITY

            THIS IS A RELEASE AND WAIVER OF LIABILITY (hereinafter referred to as "Release") made this ______ day of _____________, 20___, by and between Pine Hills Kiddie Garden ("Pine Hills") and _____________________ and ______________________ residing at _______________________________________, who are the parent(s) or guardians(s) of ________________(the "Child").

            WHEREAS, the parent(s) or Guardian(s) has engaged Pine Hills to provide a program for the child.

            NOW, THEREFORE, in consideration of the agreements and covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto hereby agree as follows:

 1.        The Parent(s) and/or Guardian(s) hereby fully and forever release and discharge the School from any and all liability, claims, demands, injuries, actions or causes of action, including attorneys' fees and costs, as a result of any action or failure to take action by Pine Hills.  The parent(s) and/or guardian(s) expressly agree that the Child's use of the Pine Hills or attendance at Pine Hills and any activities associated with Pine Hills are undertaken at the sole risk of the Child and/or Parent(s) and/or Guardians and that Pine Hills, its agents and employees shall not be liable for any damages or injuries to the Child or the property of the Child or be subject to any claim, demand, injury, action or causes of action, including but not limited to any injury or damage resulting from the negligence of Pine Hills, guests and/or other children and/or third parties.

2.         This Release shall be governed by the laws of the State of Indiana, without regard to conflict of law principles.

3.         This Release supersedes and replaces all prior negotiations and all agreements proposed or otherwise, whether written or oral, concerning all subject matters covered herein.  This Release constitutes the entire agreement among the parties with respect to the subject matters discussed herein.

4.         The reference in this Release to the term "Pine Hills" shall include Pine Hills Kiddie Garden, and all of its affiliates, subsidiaries, successor corporations, parent corporations and any and all of their directors, officers, employees, agents and representatives.  The terms Parent(s)/Guardian(s) shall include the Child and the dependents, heirs, executors, administrators, assigns and successors of the parent, guardian and/or child.

5.         The Guardians and/or Parents and/or Child recognize that the failure of any guardians, parents, and or child to comply with Pine Hills policies, guidelines, directions, regulations and or other applicable law may result in nonadmision or removal of the child from Pine Hills.  I give permission to Staff at Pine Hillspersonnel to seek emergency assistance when deemed necessary.

6.         If one or more of the provisions of this Release shall for any reason be held invalid, illegal or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect or impair any other provision of this Release. This Release shall be construed as if such invalid, illegal or unenforceable provisions had not been contained herein.

Pine Hills Kiddie Garden

By:____________________________
Name:__________________________
Title:___________________________
Date:___________________________

All Custodial Parent(s) and Guardian(s)
Of_____________________________

By:_____________________________
Name:__________________________
Title:___________________________
Date:___________________________

By:_____________________________
Name:__________________________
Title:___________________________
Date:___________________________

 

Cases & Matters by ADA Title Coverage | Legal Documents by Type & Date | ADA Home Page

October 20, 2009