Telephone: 605-852-2455
1-800-370-7908 - Fax: 605-852-2669
Finance Department 605-852-2993 - Fax: 605-852-2791
High School, Middle School
& Elementary
101 Crow Creek Loop
Stephan, S.D. 57346
605-852-2258/2416/2277
Fax # - 852-2401/2573/2181
Better Alternative School
Box 547
123 White Ghost Drive
Ft. Thompson, S.D. 57339
605-852-2258 Ext. 2100/2101
Fax: 605-245-2856
Crow Creek Admissions Returning Student Packet - Check List
The following application forms are to be read carefully and fully
completed before your application will be considered for the 2015-2016
School Year. ** Notice some forms MUST be signed & notarized.
Student Enrollment Form
Fill out and sign
Legal Custody Form
(Notarized/Mandatory)
 Medical Power of Attorney
Fill out and sign
Day Student Check Out Form
(Notarized/Mandatory)
 Social History Form
Fill out and sign
Permission/Participants Consent Forms
Fill out and sign
Parent Compact
Read carefully and sign
BIE McKinney-Vento Enrollment Form
Fill out and sign
Campus Parent/Portal
Read, complete and sign (student/Parent/Guardian)
Photo Release Form
Read, Complete and Sign
FERPA
Sign & Date
Parent/Guardian: Very IMPORTANT reminder, your child(s) application must be complete and returned to our
school before your child is officially enrolled.
Notaries for Crow Creek Tribal School:
Marcella How e
-
Middle School Registrar/Secretary
Marcia Wells
-
Elementary Registrar/Secretary
The first day of school is Sept. 8, 2015
to be considered for Perfect
Attendance, Awards and Academic Honors then you must be present beginning
Sept. 8th.
Page 3 of 20
STUDENT ENROLLMENT APPLICATION
FOR STUDENT ENROLLED IN BUREAU-FUNDED SCHOOLS
Name of School:
Type:
Day School
( )
Boarding School
( )
Peripheral Dormitory
( )
1. IDENTIFICATION
Name of Student:
(Last)
Address: P.O. Box
Funding:
Pub. Law 100-297 Grant
Pub. Law 93-638 Contract
BIA Operated
(First)
Street:
City:
State:
( )
( )
( )
(Middle)
Zip Code
Miles from home to school:
Date of Birth:
Month
Day
Sex: Male ( ) Female ( )
Tribal Affiliation:
Degree of Indian:
Enrollment Number:
Home Agency:
Dominant Language spoken in the home:
(1)
Father:
Place of Birth
Year
Verified By:
(2)
FAMILY INFORMATION
Mother:
Address:
Address:
Tribal Affiliation:
Home Agency:
Enrollment Number:
Living ( )
Dead ( )
Occupation (Optional):
Employer:
Tribal Affiliation:
Home Agency:
Enrollment Number:
Living ( )
Dead ( )
Occupation (Optional):
Employer:
Telephone Home:
Telephone Home:
Work:
Emergency:
Work:
Emergency:
Other (Specify):
Other (Specify):
Page 1
OMB Control No. 1076-0122
Expires:
08/31/2016
4. CRITERIA FOR BORADING OR OUT OF BOUNDARY ENROLLMENT:
Favorable action is recommended upon this application because this case conforms to the following criteria for
boarding school or out of boundary enrollment. If this application is for an off reservation boarding school and
for social reasons, a social summary is to accompany this application.
Education Factors
Social Factors
Federal/Public schools near student’s home:
In his/her environment, the student:
( )Do not offer grade lever
( )Was rejected or neglected
( )Are severely overcrowded
( )Does not receive adequate parental supervision
( )Do not offer student’s grade
( ) Well being was imperiled due to family behavioral
( )Exceed 11/2 miles walking distance to school or problems
bus route
( )Has behavioral problems too difficult for solution by
( )Do not offer special vocational/preparatory training family or local resources
necessary for gainful employment
( )Has siblings or other close relative enrolled who
( )Do not offer adequate provisions to meet academic would be adversely affected by separation
deficiencies or linguistic/cultural differences
( )Receiving School offers special academic
program needed by student.
Approved:
Date:
In Boundary
(Signature & title of approving official)
Approved:
Date:
Out-of-Boundary
(Signature & title of approving official)
Off-Reservation Boarding School
(Signature & title of approving official)
Privacy Act Statement: This information is collected as provided by 5 U.S.C. 552A. The Office of Indian Education
Programs is authorized to collect this information I accordance with Public Law 95-561; 98-511: 99-89; ad 100-297. The
information will be used to determine the level of funding to be distributed by formula to BIA funded elementary and
secondary schools. Weighted student units, the value of basic and specialized instructional and residential programs, are
used to calculate the distribution of funds. The information may be disclosed to appropriate Department of the Interior and
Congressional Offices for policy and budgetary purposes.
Page 5 of 20
OMB Control No. 1076-0122
Expires:
08/31/2016
2. FAMILY AND BACKGROUND INFORMATION
Parent’s Name
Father’s
Enter father’s address if different from student’s
Address:
Tribal Affiliation:
Enter father’s Tribe
Home Agency:
Enter Agency where father is enrolled
Census Number:
Enter father’s census number
Living/
Indicate whether father is alive or deceased entering date if deceased.
Deceased:
Occupation
Enter father’s occupation
(Optional)
Employer
Enter the name of father’s employer or where he works
Telephone
Please list father’s home telephone, work number, and emergency number or other
Numbers:
numbers where father can be reached in case of an emergency. If other, indicate
friend, aunt, uncle, etc.
Mother:
Same instruction as above.
Legal Guardian:
Same instruction as above
3. SCHOOLS P-REVIOUSLY ATTENDED: List the names, addresses, dates, grades completed and
reasons for leaving all the schools the student previously attended.
Please fill out as accurately as possible.
4. FOR BUREAU USE ONLY: Self-Explanatory
Crow Creek Tribal Schools
High School/Middle School
101 Crow Creek Loop
Stephan, SD 57346
LEGAL CUSTODY FORM
Is child currently under custody of the ICWA (Indian Child Welfare Act) or State or Tribal Social Services,
Department of Corrections or Other?
________ Yes ________ No
If yes, please provide a copy of custody documents. (MUST SHOW LEGAL COURT PAPERS)
I, ___________________________________________________________ have legal custody of
(Print Parent/Guardian)
____________________________________________________________as set forth by:
(Print Student Name)
Birth
Divorce Decree
Tribal Court
Other
Please attach a copy of one of the above named documents and return with application.
Is there a restraining order in place?
Yes
No
If yes, please give name of person:___________________________________________________
___________________________________
Signature of Parent/Legal Guardian
____________________________________
Verified by Notary of the Public
____________________________________
My Commission Expires on
Page 7 of 20
Medical Power of Attorney
For Care of Minor Child
I affirm that I am the parent and/or legal guardian of the minor child named below:
_________________________________________________
Child’s FULL Name
___________________________________
Date of Birth
I hereby, give consent to the Crow Creek Tribal School Nursing staff to seek and obtain routine medical and
dental care for this child at the Fort Thompson Indian Health Care Center (Dormitory or school staff may take
students under special circumstances).
In addition, I hereby give consent for the following adults to seek and obtain routine medical or dental care for
this child at Fort Thompson Indian Health Center.
SCHOOL STAFF
School Year 2015- 2016
SCHOOL NURSE
I understand that I or one of the above persons must accompany the child each time medical or dental care is
sought; otherwise care will not be given until I (or the child’s other parent) have been contacted and give
consent for care.
I further understand that this consent applies only to routine medical and dental care that I must give additional
consent for more complicated or difficult procedures. Written consent is not required for care during a serious
emergency.
THIS CONSENT EXPIRES AT THE END OF THE SCHOOL YEAR:
MAY 20, 2016
_______________________________ ________________________________ __________
Signature
Relationship
Date
_______________________________ ________________________________ __________
Signature
Relationship
Date
**Confidential-for School/Dormitory Counselor and Indian Health Service Counselor**
Crow Creek Tribal Schools
Social History – Counseling Consent Form
Name: __________________________________________________
Grade: _______________________
Consent for Counseling Services
I give permission for my child to receive counseling services from Crow Creek Tribal School or through Indian Health
Services in Fort Thompson, SD. I understand that this service will be given if and when my child’s behavior indicates the
need.
I understand that if I do not give consent for counseling services from the school or Indian Health Service, I must provide
an outside source for counseling if deemed necessary.
__________________________________________________________
Parent/Guardian Signature
____________________________
Date
****************************************************************************************
Failure to provide accurate response or no response to all questions can result in denial of application.
Are there any areas of concerns you would like the counselor to be aware of?
________________________________________________________________________________________
________________________________________________________________________________________
Has student been dropped or expelled from school?
___Yes ___No
If yes, please explain: ______________________________________________________________________
If student on probation?
___Yes ___No
If yes, please explain: ______________________________________________________________________
Please list name and phone # of probation officer or case worker:
________________________________________________________________________________________
Name
Phone #
HAS STUDENT EVER BEEN SUSPENDED OR EXPELLED FROM SCHOOL FOR ANY WEAPON
VIOLATION OR THREATS OF VIOLENCE?
___Yes ___No
If yes, please explain: _____________________________________________________________________
Has student ever received services from an impatient or outpatient treatment program or correctional program?
___Yes ___No
If yes, please explain: _____________________________________________________________________
Has student ever received services from Special Education? (e.g. is currently on an IEP)? ___Yes ___No
By signing this form, all the above information is correct to the best of my knowledge.
__________________________________________________________
Parent/Guardian Signature
____________________________
Date
Page 9 of 20
Crow Creek Tribal Schools
Campus Portal Acceptable Use Policy
Crow Creek Tribal Schools has developed a Campus Portal as a means to further promote educational excellence
and to enhance communication with parents and students. The Campus Portal allows parents and students
(Grades K-12) to view school records anywhere at any time. In response for the privilege of accessing the Crow
Creek Tribal Schools Campus Portal, every parent and student is expected to act in a responsible, ethical and legal
manner. The Campus Portal is available to every parent or guardian who has a student enrolled at Crow Creek
Tribal Schools. Parents and students are required to adhere to the following guidelines.
1. Parents and students will not share their passwords with anyone, including their children or
classmates.
2. Parents and students will not attempt to harm or destroy data of their own children, of
another user, school or district network, or the Internet.
3. Parents and student will not use the Campus Portal for any illegal activity, including
violation of Data Privacy laws. Anyone found to be violating laws will be subject to Civil
and/or Criminal Prosecution.
4. Parents and students will not access data or any account owned by another parent or student
5. Parents and students who identify a security problem with the Campus Portal must notify
the Schools Technology Coordinator immediately (852-2993) or (vjfallis@cctschieftains.org)
without demonstrating the problem to anyone else.
6. Parents and students who are identified as a security risk to the Campus Portal will be
denied access to the Campus Portal.
User guidelines and system requirements can be found at www.crowcreek.k12.sd.us. Please review them before
signing and returning this document. You are required to sign and return this agreement before you receive
access to the Campus Portal. Students must both sign and have a parent signature to gain access to the
Campus Portal.
Please fill in all blanks (Print)
Parent(s) Name: __________________________________________________
Email Address: ___________________________________________________
Children Information
Name: __________________________________________________ Grade: _________________
Name: __________________________________________________ Grade: _________________
Name: __________________________________________________ Grade: _________________
I have read the Campus Portal Acceptable Use Policy and I agree to abide by and support these rules.
I understand that if I violate any terms of this Acceptable Use Policy that I may lose my privilege to use the Campus
Portal, and may be liable for civil and/or criminal consequences.
Student Signature _________________________________________________ Date: _____________
Parent Signature: __________________________________________________ Date: _____________
Crow Creek Tribal Schools
PHOTO Release Form
All photographers taking photographs or on Crow Creek Tribal Schools property or of Crow
Creek Tribal School Events or student works must obtain a signed release form from any
student, faculty member, staff person who is visibly recognizable in the photograph. Crowd
scenes where not single person is the dominate feature are exempt.
These rules govern photographs intended for use in any Crow Creek Tribal School publication
of marketing or a public relations nature, such as newsletters, brochures, yearbooks,
promotional items, or other such material. Releases also must be obtained for photographs used
on the Web. These rules are not in effect when photographs are taken on news events, but
photographs are taken of news events, but photographs taken for news purposed required a
release for reuse in marketing materials.
*****************************************************************************
Date___________________________ Elem_____ MS_____ HS_____ ALT_____
PLEASE CHECK ONE
________
I DO give my consent for Crow Creek Tribal School to interview me or my child
(name listed below) to use in photograph(s) video in any and all of its publications
and in any and all media for use but the Crow Creek Tribal School. I will make no
monetary or other claim against Crow Creek Tribal School for the use of the
interview and/or the photographs(s) video.
________
I DO NOT give my consent for Crow Creek Tribal School to interview me or my
child (name listed below, to use in photograph(s)/video in any and all of its
publications and in any and all media for use by the Crow Creek Tribal School.
Name of child (Please Print)____________________________________________________
Parent/Guardian (Please Print)__________________________________________________
Parent/Guardian Signature_____________________________________________________
Relationship to child (if child is a minor)_________________________________________
Courtesy of L.W.S./ab/2012
****************************************************************************************
Page 11 of 20
Crow Creek Tribal Schools





Permission Form for Internet Usage in Classroom and Dormitory
General Consent for Field Trip
Religion of Choice Consent
Participation in Talented & Gifted Program in a Previous School
Internet Usage
Students at CCTS have access to the internet in computer related classes, as well as in the dormitory
 There are strict rules for Internet usage by students. As a school system we attempt to block out as many inappropriate
sites as possible, but as you may have read or heard, this can be difficult at times.
 In order for your child to be allowed any contact on the internet, we need to have your permission. Please understand that
due to certain circumstances your student may access an inappropriate site. We will not be held liable for any such
occurrences.
 If it is proved that a student has misused the internet or e-mail services, their privileges may be revoked for the remainder
of the school year.
Please check on of the following:
_____ I Do Not Give Permission for my child to be on the internet.
_____ I Do Give Permission for my child to be on the internet.
I also give permission to use my child’s picture on your website. I understand that staff will monitor student use of the internet and
agree not to hold the school liable for any unintentional incident of my child viewing an inappropriate site.
Student:_______________________________Parent:____________________________Date_________
Signature

Signature
******************************************************************************
General Consent for Field Trip
I,
_____Give
_____Do No Give, permission for my child to go on off-campus activities and events sponsored by Crow
Creek Tribal School (including middle school, high school, dormitories, Counselor and recreation programs.)
Student:_______________________________Parent:____________________________Date_________
Signature

Signature
******************************************************************************
Religion of Choice Consent
I,
_____ Give Consent
_____ Do Not Give Consent - For my child to participate in sweat lodge ceremonies or attend the
church of their choice for purposes of purification, prayers or personal spiritual guidance while attending CCTS. My child’s religion
affiliation is:_____________________________________________________
Comments:____________________________________________________________________________
Student:_______________________________Parent:____________________________Date_________
Signature

Signature
******************************************************************************
CCTS Talented & Gifted Form
Check below if your child has participated in the Talented & Gifted Program at his/her previous school.
Indicate the students eligibility when he/she was in the program.
( ) Academic Aptitude
( ) Intelligence
( ) Visual & Performing Arts
( ) Creativity
( ) Leadership
Name of School:________________________________________________________________________
**Please CONTACT the student’s previous school and have them forward their scores from SAT’S, as well as any other supporting
documents. It is imperative that the TAG office receives this information.**
Student:_______________________________Parent:____________________________Date_________
Crow Creek Tribal Schools
Parent Compact
Definition: A compact in written agreement or promise between two or more people to declare the intent of all
involved to help in achieving mutual goals.
Directions: Please read carefully the section of this compact that pertains to your responsibility, and sign at the
bottom to pledge, and then on the back of this form once per year to renew your commitment to the education of
our children.
Parent/Guardian: (Any person with a vested interested in helping this student may sign the compact in-lieu of
the parent)
I have entrusted my child to the school to help prepare them for life. In order for my child to receive a quality
education and to reach their fullest potential, I agree to:









See that my child attends school on a daily basis, and is in attendance for the day.
Support the school in its effort to maintain proper discipline.
Establish a time and place for doing homework and review homework regularly.
Maintain an open line of communication with my child and his/her teacher.
Read with my child at least 15 minutes per day and let my child see me read.
Be aware of my child’s interest and encourage their efforts.
Visit the Crow Creek Tribal School web site (www.crowcreek.k12.sd.us) on a regular basis.
Attend parent survey on an annual basis to ensure the needs of my child are addressed.
Complete necessary forms to ensure my child if officially registered with the school.
Student
Since I am investing in my future, it is important that I work to the best of my ability. Therefore, I will do the
following:






Attend school on a daily basis and arrive on time
Come to school each days with books, pens, pencils, paper, and other necessary tools for learning
Complete daily work and return homework assignments in a timely manner
Do my best to prepare myself for tests
Behave in a manner that contributes to a positive school environment
Respect classmates, school staff and myself
Teacher
Who I am and my students see me is as important as what I say, therefore, to help students achieve, I will try to
do the following:
 Demonstrate professional behavior and positive attitude
 Maintain open lines of communication with students and their parents
 Encourage students and parents by providing information about student’s progress on a regular basis
 Provide homework assignments as necessary to reinforce learning and teach responsibility
 Treat each child in a fair and equitable manner
 Help each child reach his/her maximum learning potential
 Discuss the No Child Left Behind Law and how it affects my classroom to the parent of my students
 Provide parents with any annual survey to express their needs as well as their child’s needs.
Page 13 of 20
Principal
I support active parents’ involvement in the education of their children; Therefore, I will do the following:
 Provide an environment that allows for positive communication between the school and the home
 Monitor the learning process to ensure a learning environment is being provided
 Provide an ongoing professional evaluation with staff on regular basis
 Demonstrate professional behavior and a positive attitude
 Discuss the No Child Left Behind Law and how it affects my staff and school to parents of the child
attending our school
 Provide parents with an annual survey to express their needs as well as their child’s needs.
Signature:
Parents/Guardian_____________________________________ Date____________________
Student______________________________________________ Date____________________
Teacher(s)____________________________________________ Date____________________
Teacher(s)____________________________________________ Date____________________
Teacher(s)____________________________________________ Date____________________
Teacher(s)____________________________________________ Date____________________
Teacher(s)____________________________________________ Date____________________
Teacher(s)____________________________________________ Date____________________
Teacher(s)____________________________________________ Date____________________
Teacher(s)____________________________________________ Date____________________
Principal_____________________________________________ Date____________________
Crow Creek Tribal Schools
Day Students Check out Form 2015/2016
(Dorm Students must use the Dorm Check-Out Form when checking out during school)
It is very important the Parent/Legal Guardian have this form complete and notarized for the safety of our
students. Students will not be allowed to check out of the dormitory or school unless they are released to a
person whose name appears on this permission form. Any other special circumstances will have to be referred
to a Principal, Dormitory Supervisor or Superintendent.
_____________________________________
Student Name
____________________________________
Home Reservation
_____________________________________
Parent/Legal Guardian
____________________________________
Phone # you can be reached at immediately
____________________________________________________________________________________
PO Box/Address
City
State
Zip



I hereby give the following adults permission to check out my son/daughter for week-ends or holidays.
I understand that these adults must personally pick up the student and sign him/her out from the school
(if during school hours) and from the dormitory.
I understand that off reservation students may not check out to Ft. Thompson and surrounding
communities for overnight unless with parents or legal guardian.
(Handwriting must correspond to notarized signatures at bottom of the page)
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
I also give the school permission to seek out adequate housing and transportation for my son/daughter during
emergencies.
_____________________________________
Signature of Parent/Legal Guardian
____________________________________
Verified by Notary of the Public
____________________________________
My Commission Expires on
Page 15 of 20
Family Education Rights and Privacy Act (FERPA)
The Family Education Rights and Privacy Act of 1974, commonly known as FERPA, is a
federal law that protects the privacy of student education records. Students have specific,
protection rights regarding the release of such records and FERPA requires that institutions
adhere strictly to these guidelines.
The following are statements that reflect what the Family Education Rights and Privacy Act
(FERPA) covers concerning your rights as a parent and student:











Parents are allowed to review all files and material the school has about their child.
All schools are required to follow FERPA.
The schools cannot provide a student with his/her parent’s financial records.
A student can request that doctor of his/her choice review psychiatric or treatment
records.
FERPA does not allow the students to see the same files and records that their parent can
see.
A probation officer cannot see a student’s educational records without parental consent.
The school is required to keep a list of all people who access a student’s records.
Parents are allowed to bring someone with them to review their child’s school records.
Parents are allowed to review their child’s testing protocols.
Student Special Education records are the school’s responsibility to safeguard and no file
should ever be left out of place where they can be seen by unauthorized people.
Staff members can be reprimanded for failure to safeguard student records.
If you have further questions on your rights under the FERPA law then please feel to contact
the school or visit the www (world wide web) and do a search on FERPA. This will pull up the
law, its interpretation and how it affects you as a parent/student.
By initialing this form I have read all the above information.
__________________________________________________
Parent/Guardian
________________
Date
Page 17 of 20
Crow Creek Tribal Schools
BIE McKinney-Vento Enrollment/Referral Form
This documentation is an authorization for assistance and shall be used to address the requirements to the
McKinney-Vento Act, Title X. This document will be used to ensure all providers have the necessary
information to support the child and his/her family. This is not a legal document.
Student Information
Student Name: _____________________________________________Age_________Grade_____________
Parent/Guardian: __________________________________________________________________________
Parent/Guardian/Youth Phone Number:
__________
Cell
__________
Work
__________
Shelter
_____________
Family/Friends
Residency Information
Are you a Crow Creek Tribal School student who is currently living with a parent? ___Yes
___No
Homeless Night Time Information
Are you a high school student who is currently living on your own?
___Yes
___No
Where does the student stay at night?
Unaccompanied Youth
Address/Directions_____________________________________________________________________
The family/youth has been residing within the school district boundaries and intend to stay. __________
Please Initial
The parent/guardian/youth understand that the agreed upon services are supplemental to the regular
instructional day and will be re-evaluated to determine which needs to be continued. In the event that the
family/youth residency changes, it is their responsibility to notify School Liaison/Designee immediately.
___________________________________ _________
Parent/Guardian/Youth
Date
____________________________
School Liaison/Designee
________
Date
CROW CREEK SERVICE UNIT
FT. THOMPSON HIS HEALTH CENTER
BUSINESS OFFICE
PO BOX 200
FT. THOMPSON, SD 57339
(605) 245-1540
AUTHORIZATION TO FURNISH INFORMATION
AND ASSIGNMENT OF BENEFITS
I authorize Ft. Thompson IHS Health Center to release medical information about me to my insurance carrier,
workmen’s compensation carrier or SD Medicaid.
I hereby assign insurance benefits that I may be eligible to receive, to the Ft. Thompson IHS Health Center as
payment for medical services and supplies furnished to me by the IHS. I authorized direct payment of such
benefits to the Indian Health Service, Ft. Thompson, SD 57339.
____________________________________________
Patient’s Name
____________________________________________
Patient/Parent/Guardian Signature
____________________________________________
Date
THIS CONSENT SHALL REMAIN VALID UNTIL REVOKED IN WRITING
Page 19 of 20
NOTICE TO PATIENTS
ELIGIBILITY FOR DIRECT CARE:
You must be eligible for DIRECT CARE. This care provided at the Ft. Thompson IHS Health Center.
To be eligible for DIRECT CARE you must be an Indian/Native American from a Federally Recognized
Tribe of the United States. You may reside anywhere within the United States. You are allowed up to 30
days to provide proof of being Indian/Native American and allowed 1 clinic visit. Proof shall be in the
form of a letter, statement, or BIA Form 4432 from your Tribe, Which contains either enrollment
number or degree of Indian Blood OR if NOT enrolled, proof of decadency/Lineage. It is the
responsibility of the patient to obtain this proof. If proof is not shown within the time frame specified
further services WILL NOT be allowed at the Ft. Thompson IHS Health Center.
A medical doctor of the IHS may refer a person when the medical care required cannot be provided by
the Ft. Thompson IHS Health Center. IHS WILL NOT AUTHORIZE PAYMENT for this care until the
following eligibility requirements are met.
ELIGIBILITY FOR PATIENT REFERRALS:
You must be eligible for CONTRACT HEALTH CARE. This is care provided away from the IHS
Facility. You must first meet the Direct Care requirements and you must reside within a delivery area
called the “ON or NEAR Regulation” The “ON” refers to an Indian/Native American eligible for Direct
Care and lives within the boundaries of the Crow Creek Sioux Reservation. The “NEAR” refers to the
members of the Crow Creek Sioux Tribe who live near the Crow Creek reservation where the Ft.
Thompson IHS Health Center is located. Members of the Crow Creek Sioux Tribe who reside within our
CHS delivery is (i.e., Buffalo, Brule, Hand, Hughes, Hyde, Lyman, and Stanley Counties) will meet the
“NEAR” regulation. If the patient is not enrolled with the Crow Creek Sioux Tribe and “DOES NOT”
live on the Crow Creek Reservation the patient “IS NOT” eligible for Contract Health Services.
If the patient does not meet BOTH eligibility requirements for DIRECT CARE and Contract Health Care, “IHS
WILL NOT PAY” for care provided at a non-IHS health care facility.
NON-INDIAN BENEFICARIES:
Any Non-Indian woman pregnant with an eligible Indian/Native American child will be required to
show proof that she is eligible for prenatal and postnatal services either through marriage to an eligible
Indian/Native American male or by statement from the eligible Indian/Native American that she is
carrying his child.
I have read & received a copy of the above information.
______________________________________________
Signature
__________________
Date
ACKNOWLEDGEMENT OF RECEIPT OF IHS NOTICE OF PRIVACY PRACTICES
I HEREBY ACKNOWLEDGE RECEIPT OF THE INDIAN HEALTH SERVICE (IHS) NOTICE OF
PRIVACY PRACTICES AT:
FORT THOMPSON INDIAN HEALTH SERVICES
PO BOX 200
FORT THOMPSON, SOUTH DAKOTA 57339
___________________________________________
Signature of Patient
________________________
Date
___________________________________________
Signature of Patient Representative
________________________
Date
(State relationship to patient or witness (if signature is by thumb print or mark)
___________________________________________
Signature and Title of IHS Employee
________________________
Date
FOR PATIENTS UNABLE TO ACKNOWLEDGE RECEIPT
I HEREBY CERTIFY THAT THE PATIENT WAS UNABLE TO ACKNOWLEDGE RECEIPT OF THE IHS
NOTICE OF PRIVACY PRACTICES
BECAUSE____________________________________________________________________
___________________________________________
Signature of IHS Employee
________________________
Date