Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Valley Collaborative
Transitional High School
Alternative Site
Linnell Circle
Billerica, MA 01821
Program Information
2015-2016
Building a community that empowers children and adults to find their own way.
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Dear Parent,
Thank you for choosing the Valley Collaborative. Enclosed you will find all of the information
necessary for your child to begin his/her Interim Alternative Education Setting 45-Day Assessment.
It is imperative that you are thorough when filling out these materials. Please return this packet to
Julie Fielding before your child’s first day. An interview with you and your child prior to his/her
start date will be scheduled. This will help us in facilitating the assessment process and will allow
the student and parents to have an opportunity to ask questions or voice concerns.
The Interim Alternative Educational Setting provides an environment where psychosocial needs of
each student are assessed in a small, structured setting. Students may be placed up to 45 school
days, in order to develop clear recommendations and plan for the students’ school district. We offer
an integrated approach, which means the 45-Day students are placed in classrooms with their grade
level peers. They will participate in curriculum which corresponds to their grade level curriculum
under the Massachusetts state frameworks. Complete formal and informal assessments are
conducted and a written report is presented at the termination team meeting.
If you have any questions, please feel free to call.
Sincerely,
Julie Fielding
Julie Fielding
Transitional High School Principal – Alternative Programming
[email protected]
(978) 528-7834
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
What is a IAES 45-day assessment?
Clinical Component:
A student is referred for an assessment to determine the most appropriate Interim Alternative Educational
Setting (IAES) and/or be provided with recommendations of how to work best with the student. This task
is accomplished by administrating various psycho/social assessment tools/tests, observing classroom
behaviors, interviewing the student and family, and contacting various collaterals that are involved with
the student. At the end of the 45-day period, a team meeting will take place at the Valley Collaborative
where recommendations are discussed.
Educational Component:
The Valley Collaborative 45-Day Assessment ensures the continuity of the students’ curriculum during the
assessment period. Students are provided both small group and individualized instruction following the
Massachusetts state frameworks for the student’s grade level. Please keep in mind that the student has been
referred for an assessment to determine the most appropriate educational setting and at the close of the
evaluation, recommendations will be provided.
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Parent/Guardian IAES 45 Day Checklist:
Please Note: It is the responsibility of the Parent/Guardian to return this packet two days
prior to your student’s arrival. Brittany Maiuri, school social worker, will need this information
prior to your student’s admission:
1. Completed Emergency Paperwork Packet including:
_____Release/Request of Information form
_____Emergency Contact Names and Numbers
_____Emergency Medical Information form
_____Physicians Order form (for any student taking medication at school)
_____Photo Release form
_____Receipt of Behavior Management Policy
_____Standing Orders Parental Permission form
2. Assessment Tools:
_____BRP-2 checklist
_____Achenbach (light blue form)
_____Pre-Referral Checklist
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Valley Collaborative Transitional High School Parent/Student Checklist
 Parent/Guardian Letter
 Philosophy (Requires Parent/Guardian and Student Signatures)
 Disciplinary Policy (Requires Parent/Guardian Signature and Student Initials)
 Anti-Hazing Law (Please retain for your records)
 Anti-Hazing Policy (Requires Parent/Guardian and Student Signatures)
 Student Internet/Email Usage Policy (Please retain for your records)
 Internet/Technology Student Agreement (Requires Parent/Guardian and Student Signatures)
 Audio, Photograph, Videotape & Website Information & Agreement Form
(Requires Parent/Guardian Signature)
 Field Trip/Transportation Authorization (Requires Parent/Guardian Signature)
 Authorization to Release/Request Confidential Information
 Authorization for Student Participation in the Experiential Physical Education Program
 Academic School Calendar (Please retain for your records)
If you are missing any of these forms, please contact us and we will send them to you.
Your signature indicates your understanding and agreement to the enclosed information.
Parent/Guardian/Caregiver’s Signature: ____________________________
Date: _______________________________
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Dear Parents and Guardians:
The Valley Collaborative Transitional High School is an alternative educational setting providing both
academic and social-emotional education to adolescents who are not meeting the demands of the more
traditional academic environments. Students will develop both academic and social skills toward the
goal of becoming responsible contributing adults.
In the program, we utilize the Positive behavioral interventions and supports (PBIS) framework and a
therapeutic group processing approach. Positive choices are reinforced by earning rewards and
negative choices or behaviors are dealt with “in the moment” with a therapeutic community group
focusing on learning and moving forward.
An Extended Support Center also exists for more challenging times. Here, individual students will
have access to curriculum-based academic assistance, therapeutic support to help process unresolved
issues, problem-solve, and make better choices moving forward. The E.S.C. is staffed by certified
teachers, paraprofessionals, and a social worker.
Please take this opportunity to talk to your child about the expectations at school and the importance of
demonstrating positive decision making. With your support and involvement, Valley will remain a
school where students can excel.
Julie Fielding, LICSW
Program Lead
Alternative High School
Valley Collaborative
All students must read the following description of the Valley Collaborative program and the
Therapy philosophy that is utilized. Once complete, the student must sign at the bottom of the
last page.
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Valley Collaborative Transitional High School Frameworks
.
PBIS:
The students at Valley learn about school-wide behavioral expectations. Staff teach expected behaviors
and recognize positivity. These expectations have been agreed upon by the staff as an effective way to
be proactive in managing behaviors. Students earn tickets for making positive choices in a targeted
area. These tickets are turned in for prizes such as gift cards, lunches, and other unique prizes.
Therapeutic Community Group:
The group processing approach consists of seven basic principles:
1)
2)
3)
4)
5)
6)
7)
Establish rapport/relationships with the students.
Deal with present behaviors…i.e., ask “what”, not “why”.
Have the students make a value judgment regarding behavior/attitude.
Make a plan to deal with the behavior/attitude.
Get a commitment of the plan from the students.
Accept NO excuses - show the students they can control themselves and the situation.
Do not use punishment – only natural consequences; the responsibility for change is
then on the students.
To this end, a peer group is developed within the school community. Both positive and negative
behaviors and attitudes are addressed and confronted in the group situation. The students are made
aware of these behaviors and make a commitment to the group to change. The students are taking
responsibility for themselves. Through this process the students learn that they are capable of behaving
in a responsible manner, that they are capable of making good decisions, and consequently increasing
their self-esteem.
EXPERIENCE FEELINGS, ACCEPT THEM, SHARE THEM = BE SAFE
I HAVE READ AND UNDERSTAND THE
PHILOSOPHY DESCRIBED ABOVE.
____________________________________
Parent / Guardian Signature
______________________
Date
____________________________________
Student Signature
______________________
Date
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Valley Collaborative Transitional High School
Disciplinary Policy
Appropriate behavior, attitude and language are expected of all students attending
Valley Collaborative Transitional High School
Rules
Please read and initial on the small line under each section.
1) No drugs or alcohol in school. Do not come to school under the influence of substances.
2) No weapons, violence or threats of violence;
3) No destruction of property;
4) No stealing;
5) No leaving the school building without permission;
6) No using the phone without permission;
7) No smoking in the school building;
8) No driving to school or being picked up from school without permission;
9) Appropriate attendance is required
X________
Interventions
Group
Group is utilized as part of the reality therapy process. Group is used to discuss various behaviors
and attitudes, to discuss rules and to encourage students in their understanding of school rules.
X________
Time Out
Time out is used when a student feels the need to distance him/herself from a certain situation to
gain control. We do not have a “time out room”. Students use a quiet area in the school when they
require this intervention.
X________
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Physical Restrain
The Program does not utilize physical restraint as a regular means of discipline. There is no crisis
room. Should a student consistently lose control and become harmful to him/herself or others,
physical intervention may be required. This is viewed as a very serious matter and would require
the necessary meetings and discussions to determine if placement at Valley Collaborative is
appropriate.
X________
Therapeutic Leave/Suspension
A student may be asked to take a therapeutic leave from the program to think about his/her
behavior and attitude. A student would be suspended for serious rule infractions as outlined below.
In either case an incident report would be filed and sent to the LEA following a phone call to notify
the school. Parents would be contacted as well as any other agency that is involved with the
student. A meeting would be held in both cases with all necessary parties to discuss the
incident/behavior and determine whether continued placement at Valley Collaborative is
appropriate.
X________
Rule Violations
Drugs and Alcohol
A student will be suspended from school if drugs or alcohol are brought into the school. The police
will be notified and charges will be pressed. A meeting will be held with all collateral’s to discuss
the incident and determine subsequent consequences. A student may be required to terminate from
the program for this rule violation.
If a student comes to school under the influence of substances or is suspected of being under the
influence of substances, the parent or guardian will be contacted and they will be required to come
and take the student home. A meeting will be held with collateral’s to discuss the incident and
subsequent consequences (i.e., substance abuse treatment, evaluations, etc.).
X________
Weapons / Violence / Threats of Violence
Possession of a weapon of any sort is prohibited. Under the Gun Free School Act, state law
requires that a student be expelled from school for not less than a year if they have brought a
firearm to school. Acts of violence to threats of violence are also prohibited. Weapon possession
and acts of violence will result in suspension. Threats of violence may result in a therapeutic leave.
Meetings would be held with all collateral’s to discuss subsequent termination from the program as
it impacts on the safety of all others in the environment.
X________
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Destruction of Property
If students destroy property, they will be responsible for financially replacing that property. Their
parents or guardian will be notified to arrange repayment. If the destruction involves a serious act
of violence, the steps above would also be taken.
X________
Stealing
Trading and other acts of exchange are not encouraged. Students who steal will be confronted in
the group. Parents / guardians will be notified. Stolen items will need to be replaced. Serious acts
of theft may result in more serious consequences.
X________
Leaving the School without Permission
In accordance with reality therapy, students who get angry and choose to leave the school grounds
without permission will not be forcibly held back. At times, testing this decision-making
opportunity is beneficial to the student. Should a student leave grounds without permission, the
parent(s) and the Special Education Director will be notified immediately.
X________
Using the Phone without Permission
Students are not allowed to use the phone without permission. Phone calls may be made with staff
approval. At times, staff may choose to monitor phone calls. If the privilege is abused, the issue
will be taken to group. Further abuse of the rule could result in the complete loss of phone
privileges for all students.
X________
Driving to School / Being Picked Up from School
Students are not allowed to drive to school. If a student has made the honor roll and has a specific
reason why he / she should be able to drive to school, they may petition the program. The staff
would then make a decision and notify the Collaborative Director as well as the Special Education
Director of the student’s town to obtain their permission. Students cannot be driven to school or
picked up from school without staff and parental permission. Parents need to complete a
transportation permission slip when students are enrolled in the program. Students will only be
allowed to be transported by those people the parent has indicated are appropriate. If any of these
people become disruptive to the school environment, the school has the authority to not allow that
person on school grounds.
X________
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Attendance
Students are expected to attend school. If a student is to be absent, he / she is to contact the school
between 8:00am and 8:15am. If there is a question about the validity of an absence or if no call has
been received, parents will be contacted. An attendance report is sent to each student’s LEA at the
end of every month. If truancy is an issue, a meeting will be held with collateral’s to discuss the
appropriateness of the placement.
X________
Dress
Appropriate dress is required. Clothing with drug, alcohol, sexual, or violent motifs are not
allowed. Mesh shirts are not allowed. Shorts need to be an appropriate length. Students should
not wear half shirts or clothing that exposes a lot of “skin”.
Problems with appropriate dress will be addressed with the student, the parent and possibly ingroup. In extreme cases, the student may be sent home.
X________
I HAVE READ AND UNDERSTAND THE
DISCIPLINARY MEASURES LISTED ABOVE.
__________________________________
Parent / Guardian Signature
_________________
Date
__________________________________
Student Signature
_________________
Date
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Anti-Hazing
PLEASE RETAIN THIS DOCUMENT FOR YOUR RECORDS
Chapter 269: Section 17
Crime of Hazing, Definition, Penalty
Whoever is a principal organizer or participant in the crime of hazing, as defined herein, shall be
punished by a fine of not more than three thousand dollars or by imprisonment in a house of
correction for not more than one year, or both such fine and imprisonment.
The term “hazing” as used in this section and in sections eighteen and nineteen, shall mean any
conduct or method of initiation into any student organization, whether on public or private
property, which willfully or recklessly endangers the physical or mental health of any student or
other person. Such conduct shall include whipping, beating, branding, forced calisthenics, exposure
to the weather, forced consumption of any food, liquor, beverage, drug or other substance, or any
other brutal treatment or forced physical activity which is likely to adversely affect the physical
health or safety of any such student or other person, or which subjects such student or other person
to extreme mental stress, including extended deprivation of sleep or rest or extended isolation.
Notwithstanding any other provisions of this section to the contrary, consent shall not be available
as a defense to any prosecution under this action.
Chapter 269: Section 18
Duty to report Hazing
Whoever knows that another person is the victim of hazing as defined in section seventeen and is at
the scene of such crime shall, to the extent that such person can do so without danger or peril to
himself or others, report such crime to an appropriate law enforcement official as soon as
reasonably practicable. Whoever fails to report such crime shall be punished by a fine of not more
than one thousand dollars.
Chapter 269: Section 19.
Statutes to be Provided to Student Groups; Compliance Statement and Discipline Policy Required
Section 19. Each institution of secondary education and each public and private institution of postsecondary education shall issue to every student group, student team or student organization which
is part of such institution or is recognized by the institution or permitted by the institution to use its
name or facilities or is known by the institution to exist as an unaffiliated student group, student
team or student organization, a copy of this section and sections seventeen and eighteen; provided,
however, that an institution’s compliance with this section’s requirements that an institution issue
copies of this section and sections seventeen and eighteen to unaffiliated student groups, teams or
organizations shall not constitute evidence of the institution’s recognition or endorsement of said
unaffiliated student groups, teams or organizations.
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Each such group, team or organization shall distribute a copy of this section and sections seventeen
and eighteen to each of its members, plebes, pledges or applicants for membership. It shall be the
duty of each such group, team or organization, acting through its designated officer, to deliver
annually, to the institution an attested acknowledgement stating that such group, team or
organization has received a copy of this section and said sections seventeen and eighteen, that each
of its members, plebes, pledges, or applicants has received a copy of sections seventeen and
eighteen, and that such group, team or organization understands and agrees to comply with the
provisions of this section and sections seventeen and eighteen.
Each institution of secondary education and each public or private institution of post-secondary
education shall, at least annually, before or at the start of enrollment, deliver to each person who
enrolls as a full time student in such institution a copy of this section and sections seventeen and
eighteen.
Each institution of secondary education and each public or private institution of post-secondary
education shall file, at least annually, a report with the board of higher education and in the case of
secondary institutions, the board of education, certifying that such institution has complied with its
responsibility to inform student groups, teams or organizations and to notify each full time student
enrolled by it of the provisions of this section and sections seventeen and eighteen and also
certifying that said institution has adopted a disciplinary policy with regard to the organizers and
participants of hazing, and that such policy has been set forth with appropriate emphasis in the
student handbook or similar means of communicating the institution’s policies to its students. The
board of higher education and, in the case of secondary institutions, the board of education shall
promulgate regulations governing the content and frequency of such reports, and shall forthwith
report to the attorney general any such institution which fails to make such report.
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Valley Collaborative Anti-Hazing Policy
In accordance with Massachusetts General Laws, Chapter 536 of the Acts of 1985, the Valley
Collaborative (hereinafter “Collaborative”) hereby deems that no student, employee or school
organization under the control of the Collaborative shall engage in the activity of hazing a student
while on or off school property, or at a school sponsored event regardless of the location. No
organization that uses the facilities or grounds under the control of the Collaborative shall engage
in the activity of hazing any person while on school property.
Hazing is defined in Chapter 269, Section 17 of the Massachusetts General Laws as follows:
The term “hazing” shall mean any conduct or method of initiation into any student organization,
whether on public or private property, which willfully or recklessly endangers the physical or
mental health of any student or other person. Such conduct shall include whipping, beating,
branding, forced calisthenics, exposure to the weather, forced consumption of any food, liquor,
beverage, drug or other substance, or any other brutal treatment or forced physical activity which
is likely to adversely affect the physical health or safety of any such student or other person, or
which subjects such student or other person to extreme mental stress, including extended
deprivation of sleep or rest or extended isolation.
Any student who observes what appears to them to be the activity of hazing another student or
person should report such information to the Program Director or his/her designee including the
time, date, location, names of identifiable participants and the types of behavior exhibited. Students
and employees of the Collaborative are obligated by law to report incidents of hazing to the police
department.
Any student who is present at a hazing has the obligation to report such an incident. Failure to do
so may result in disciplinary action by the Collaborative against that student and could involve
suspension from school for up to three days.
Any student who participates in the hazing of another student or other person may, upon the
approval of the Director of the Collaborative, be suspended from school for up to ten (10) school
days.
Any student determined by the Director of the Collaborative to be the organizer of a hazing activity
may be recommended for termination from the Collaborative program but will receive no less
disciplinary action than that of a participant.
In all cases relating to hazing, students will receive procedural due process.
LEGAL REF.: M.G.L. 269:17, 18, 19
Student Signature: _______________________________________________________________
Parent/Guardian Signature: ________________________________________________________
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Student Internet/Email Usage Policy
Students should read this policy and complete the Signature Form
The Signature Form is required.
PLEASE RETAIN THIS DOCUMENT FOR YOUR RECORDS
Introduction
Valley Collaborative aims to provide students with accessible, up-to-date and reliable information to
support you in your studies and educational experience. This goal requires us to provide access to the
vast information resources of the Internet to help you in your studies and to be well-informed. The
Internet is an educational tool for MSEC. Users must understand that this access is for educational
purposes and not for non-educational activities. Students will be utilizing the Internet, but WILL NOT
have access to email or instant messaging.
Internet Use
Valley Collaborative provides students with Internet access in most classrooms and some locations
have computer labs. All students may have access to the Internet. Students who wish this access must
read and sign the “Student Internet/Email Usage Policy” form.
Authorized Use
Valley Collaborative’s Internet connection is intended primarily for educational use. That means we
expect you to use your Internet access primarily for education-related purposes, i.e. to research relevant
topics and to obtain useful information. The following are specific provisions regarding authorized use
of MSEC's Internet connection:
 Users may use Valley Collaborative’s Internet services for personal improvement provided that
such use is consistent with staff and educational conduct.
 Internet use should be restricted to sites and materials such as news or information that might be
considered reasonable if read as a text publication in a classroom or library environment.
Unauthorized Use
Users shall not use Valley Collabortive’s Internet services to view, download, save, receive, or
send material related to the following:
 Offensive content of any kind, including pornographic material.
 Propagating a virus, worm, Trojan horse, or trap-door program code.
 Disabling or overload any computer system or network.
 Circumventing any system intended to protect the privacy or security of another user.
 Promoting discrimination on the basis of race, gender, national origin, age, marital status, or disability.
 Visiting web sites that promote threatening or violent behavior.
 Using the Internet for illegal activities including the illegal downloading of music, movies, or other
copyrighted materials.
 Distributing commercial messages.
 Gambling web sites.
 Hosting of ‘game servers’ for online or network gaming.
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Valley Collaborative Transitional High School
Internet/Technology Student Agreement and Parental Permission Form
2014-2015 School Year
As a user of the Internet and other technologies offered by Valley Collaborative, I have read,
fully understand, and will comply with Valley Collaborative’s Acceptable Use Policy.
Student Signature: _______________________
Student Advisor: _______________________
Date: _________________________________
As the parent or legal guardian of the above student, I give permission for him or her to use the
Internet and other network technologies offered by Valley Collaborative. I understand the rules of
the Acceptable Use Policy and also understand the consequences if said rules are not followed.
I hereby release Valley Collaborative and its employees from any and all liability arising from my
child's use, or inability to use, Valley Collaborative’s Internet and/or other networking systems.
Parent/Guardian Signature: ______________________________ Date: ____________
Name of Student: ______________________________________ Date: ____________
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
Audiotape, Photograph, Videotape & Website
Information and Agreement Form
Student Name: _________________________ DOB: ____________
We have found it to be very beneficial to use photos, audiotape, and videotape in our classrooms
in order to:
 help students express themselves
 improve communication by using pictures to describe situations and sequence events
 facilitate understanding of routines, schedules, and roles
 improve communication with parents by allowing them to view their child’s performance at school
 improve students sense of how they come across to others in various situations
 improve students understanding of group process, sequencing of events, visual processing, and
memory
 document events for community meetings and celebrations
Permission to Publish Photos on the Valley Collaborative Website
Photos of classroom activities, field trips, and school events enrich the school’s website
(www.valleycollaborative.org). Parent/Guardian consent is required to allow the faculty to publish
photos containing students on the school website. To protect students' identities, the names or other
personal information of students will not be published on the website. Only faculty will be allowed
to add photographs to the school website. For further information please refer to the Children’s
Online Privacy Protection Act of 1998 (www.ftc.gov/ogc/coppa1.htm).
Parent/Guardian's Consent
I am the parent or the legal guardian of the above-named student and give consent as indicated
below:
Yes
No
Permission for Audiotape, Photographs, Videotape
Permission to Publish Photos on the Valley
Collaborative Website
Parent/Guardian Signature
Date
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
FIELD TRIP TRANSPORTATION AUTHORIZATION
_____________________________ (Student Name) has permission to be transported in
Valley Collaborative vans for field trips, physical education, and other school activities.
_____________________________
Parent / Guardian Signature
__________________
Date
************************************************************************
ALTERNATIVE TRANSPORTATION AUTHORIZATION
If you give your permission for your son / daughter to go home via alternative
transportation, please sign below and return this completed form to the school. It is
important to recognize that neither the school nor the transportation company is
responsible for your child if they use alternative transportation.
I grant permission for my son / daughter __________________________ to be picked up
from school and driven home by:
Driver’s Name
Guardian’s Signature
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
This form will be kept in your son’s / daughter’s file and we will allow your child to
leave school with the designated drivers. Please check _____ if you would like a phone
call before your child is taken home via this list.
Building a community that empowers children and adults to find their own way
Valley Collaborative
Transitional High School IAES 45 Day Assessment
40 Linnell Circle, Billerica MA 01821 * Tel: (978)-528-7800 * http://www.valleycollaborative.org
AUTHORIZATION TO RELEASE/REQUEST CONFIDENTIAL INFORMATION
I, _______________________________________________, hereby authorize Valley Collaborative
Parent/Guardian Name
to send or receive information from the period: __________________
MM/DD/YYYY
to
__________________
MM/DD/YYYY
concerning my child: ___________________________; ___________________________; _____________
Student’s FIRST Name
LAST Name
Date of Birth
From the following person/hospital/agency:
1.) ____________________________________
Name of Person/Hospital/Agency
____________________________ _____________________
Contact Person
Phone
2.) ____________________________________
Name of Person/Hospital/Agency
____________________________ _____________________
Contact Person
Phone
3.) ____________________________________
Name of Person/Hospital/Agency
___________________________ _______________________
Contact Person
Phone
4.) ____________________________________
Name of Person/Hospital/Agency
____________________________ ______________________
Contact Person
Phone
The purpose for the release is: _____________________________________________________________________
I, the undersigned, understand that I may revoke this consent at any time by giving notice to my clinician.
However, I also understand that any information released prior to my revoking this authorization shall not be
a breach of my right to confidentiality.
To the party receiving this information: This information has been disclosed to you from
records whose confidentiality is protected by federal law. Federal regulations (42) CFR Part 2
prohibit you from making any further disclosure of it without the specific written consent of the
person to whom it pertains, or as otherwise permitted by such regulations. A general authorization
for the release of medical or other information is not sufficient for this purpose.
FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2.
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Signature of Valley Collaborative Transitional High School Principal
____________________
Date of Signature
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Signature of Parent/Guardian
Date of Signature
Building a community that empowers children and adults to find their own way