331 VT Rte 110, Chelsea, Vermont 05038 jallen@brookhaventlc.org 802 685.4458

2019-2020 Learning Center Enrollment Documents

Welcome to our Learning Center, 

Below you will find the individual links for the Brookhaven Learning Center Enrollment Documents needed. 

Reminder: Effective June 21, 2019, admission/enrollment packets and agreements outlining the services and costs associated with services for students provided by Brookhaven Treatment and Learning Center must be signed prior to the student’s determined start date. If contracts are not signed by the LEA at this time and/or paperwork required by parent(s)/guardians(s) are not complete, services will not be provided, and the student cannot attend until admission packets and contract paperwork is complete and on file at Brookhaven.

At this time, the start date is considered to be August 27, 2019, the first day of school. If paperwork is not completed by August 26, 2019, your student(s) will not be able to attend school until complete. 

Thank you for your understanding.

Please let us know if you have any questions or need  assistance with any of the paperwork. 

Thank you.

Brookhaven Learning Center

Contact: Ashley Grote

FormCompleted by/Notes
Client Information FormParent/Guardian
Brookhaven Student Health FormParent/Guardian
Consent for Time Out and Physical InterventionsParent/Guardian
Learning Center Consent to Act as Emergency Care AgentParent/Guardian
Release of Information Form
Parent/Guardian
/Sending School:

(1 for each
provider)
Authorization to Dispense Prescription MedicationParent/Guardian & Prescribing Physician (if applicable)
(must be completed,
even if student
does not take
medication
during the school
day)
Consent for PhotographParent/Guardian
Handbook and Policy AcknowledgementParent/Guardian
School-to-Home Communication Parent/Guardian
Bullying Policy and Disciplinary ProtocolParent/Guardian
Individual Crisis Management Plan (Initial Intake)Parent/Guardian
Immunization RecordsPhysician
(Contact student’s
physician to have
records faxed to
(802) 685-3094
Attention:
Ashley Grote)
Technology Acceptable Use FormParent/Guardian/Student
FERPA Disclosure and AcknowledgementParent/Guardian
Learning Center Treatment Consent FormParent/Guardian
Placing Agency
Activity Release FormParent/Guardian
Thank you for your interest in Brookhaven Treatment and Learning Center! Your contribution to Brookhaven can make a difference today and in the future for some of our challenged young people.

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