2022-23 Teaching Professions Consent & Release Forms
GOCAPS classes occur outside the traditional educational classroom. The educational opportunities provided by GOCAPS may also be enhanced by providing new and varied educational experiences. These experiences may include activities at off-site locations where the students directly observe and experience medical, manufacturing or other processes under the supervision of GOCAPS personnel and employees of our GOCAPS partners. As a result, the supervision provided to GOCAPS students may be different or reduced from the supervision the students normally have in a traditional classroom setting.  It is also important to understand that the direct educational experiences provided by the GOCAPS program may have dangers and hazards which are not present in a school setting. Since the GOCAPS programs are so diverse, it is impossible to fully describe the nature of each program. However, GOCAPS personnel are always available to discuss and explain individual programs and resolve any concerns Parents/Guardians may have concerning their student's participation in the program.
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GOCAPS classes will be held away from your student's home high school.  Transportation to and from GOCAPS classes is not included in the GO CAPS Program and is the responsibility of the Parent/Guardian.

1. GOCAPS employees and the District do not have custody or control over student participants and are not responsible for the supervision of the student participants during the time they travel to or from the student's home or high school to the site of the GOCAPS programs.

2. It is the responsibility of the student’s Parent/Guardian to select and secure the mode of transportation for their student and to ensure that their student uses the mode of transportation authorized by the parent. It is the responsibility of the parent/guardian to notify GOCAPS and the District of any restrictions which apply to their student’s transportation. GOCAPS and the District shall not be responsible for ensuring that the student uses the mode of transportation authorized by the parent.

3. The driver who is selected by the student’s Parent/Guardian and/or with whom the student rides to or from GOCAPS program locations, is not driving on behalf of, or as an employee or agent of GOCAPS or the District.  Neither GOCAPS nor the District have verified or have any duty to verify that the driver selected by the student’s Parents/Guardians is properly licensed to operate a motor vehicle in the State of Missouri, has an acceptable driving record, has appropriate liability insurance on the vehicle, or that the condition of the vehicle is acceptable.

The District or GOCAPS may arrange transportation for some GOCAPS classes, trips, or students. Transportation arranged through charter vendors may be offered for some programs when available. By prior written agreement and permission from individual Parents/Guardians, transportation may be arranged with private vehicles owned and driven by District employees, or Commercial transportation (taxi or bus).  
RELEASE*                                                                                I/We have read the above information and understand that participation in the GO CAPS program may create an increased risk for our student.                                                                                                                                                                                               I/We understand that we are responsible for our student’s transportation related to GO CAPS, and agree to accept that responsibility with the following limitations: (check all that apply): *
The District or GOCAPS may arrange transportation for some GOCAPS classes, trips, or students. Transportation arranged through charter vendors may be offered for some programs when available. By prior written agreement and permission from individual Parents/Guardians, transportation may be arranged with private vehicles owned and driven by District employees, or Commercial transportation (taxi or bus).   *
Social media and text messaging are forms of communications that GO CAPS staff may use to communicate with students for education related purposes. Use of these tools is not required and no parent should feel that their decision not to allow their student to communicate in this manner will have an impact on their student. Your child’s home high school district has policies and procedures in place that set out the expectations and requirements for staff members who choose to utilize these tools. GO CAPS employees who maintain a social networking site for the purpose of communicating with students and parents such as a team or club site will:

1. Ensure that the purpose of the site is solely educational; Keep the site private and accessible only to the students and their parents who are currently involved;
2. Limit communication to matters, volume, and times within the scope of the employee's professional responsibilities;
3. Regularly monitor the site; maintain privacy settings on the social media site to ensure posts are made available to all members;
4. Follow all home school district policies, rules, and expectations which apply to
participation in the social media site regardless of the physical location of the person participating in the social media site.

 I give my student permission to access and use social media with GO CAPS staff for educational purposes. I understand that I have a right to participate in the social media site and receive the same information my child does. I understand I can withdraw permission for my child to participate at any time by giving written notice to the staff member responsible for the site.

I give permission for my student to communicate with the instructor, business partner or mentor via text messaging.
Parent/Guardian Name* *
Parent/Guardian Cell Phone Number* *
Parent/Guardian Email *
Parent/Guardian Signature *
Student Name* *
Student Cell Phone Number *
Student Signature *
GO CAPS will be taking photographs of students and staff during the 2021-22 school year. These photographs may be used in marketing and informational materials produced by GO CAPS and distributed to the public via print publications, websites, social media and other promotional materials. They may also be used to market the GO CAPS program by our partners, CoxHealth, Mercy, Springfield ReManufacturing and The eFactory and participating school districts.

If you are NOT willing for your child to be photographed, please sign and return the consent form below.  If you have any questions, please call the GOCAPS Office at (417-991-2312).  


By my signature below, I DO NOT grant permission for my child, to be photographed by GOCAPS and partners, CoxHealth, Mercy, Lebanon ReManufacturing, The eFactory, and participating school districts for use in various print and online promotional materials for the GOCAPS program. I hereby release and hold harmless GOCAPS and mentioned partners from any reasonable expectation of privacy or confidentiality for myself and for the minor child named above associated with the images to be taken. Further, I attest that I am the parent or legal guardian of the child named above and that I have full authority to consent and authorize GO CAPS to use their likenesses. Further, I understand that neither I, nor the child named above will receive financial compensation of any type associated with the taking or publication of these photographs.
Parent/Guardian Signature *
My minor child has been selected to participate in the Greater Ozarks CAPS program (“GOCAPS”), which requires drug testing as a condition of enrollment/participation in the program. This annual test must be completed prior to the first day of class each year.  The deadline for testing this school year is August 2022.

I, the undersigned parent/legal guardian of the minor child named below, do hereby authorize and consent to a urine drug screening test to be performed on my minor child.  I understand that the drug test to be performed is a twelve panel screen, which tests for cocaine, amphetamines, barbiturates, benzodiazepines, marijuana, opiates, phencyclidine, propoxyphene, oxycodone, methamphetamine, methadone and MDMA.  I understand that the results of the drug test will be reported to CoxHealth, Mercy Lebanon Communities and GOCAPS.

Should the results of a laboratory confirmation test indicate the presence of a drug or drugs in my student's test, I give permission for the GOCAPS coordinator to contact me (parent/legal guardian) to discuss the test results. I understand the Executive Director can offer and/or I may request the test results be reviewed by a Medical Review Officer (MRO) to determine if a legal medical explanation exists for the presence of a drug or drugs. If the MRO does not review test results, or if the MRO cannot verify a legitimate medical reason for the presence of a drug or drugs in the test result, the test will be deemed as positive.  I further understand the decision of the MRO/GO CAPS will be final.  I also understand that a positive test will result in my student being refused enrollment or dismissed from continuing participation in the GOCAPS program.
Date *
Name of Parent/Guardian *
Parent/Guardian Phone Number *
Name of Minor Child (First and Last Name)* *
DOB of Minor Child *
Signature of Parent/Guardian *
Health Inventory
Please note: You will need to pick this up at orientation or email Ann Hopper at coordinator@gocapslakeregion.com:      
Once all fields have been filled, please email the document to coordinator@gocapslakeregion.com.
All students must provide documentation that meets the 2022-23 Missouri School Immunization Requirements. If you update your records over the summer, please send documentation to coordinator@gocapslakeregion.com
Mercy, Lake Regional & Cox Hospital Immunization Requirements:
Proof of the following vaccinations will be needed as well as completion of other requirements:
OSHA Blood Borne Pathogen Regulations:  District shall ensure that, where appropriate, all Instructors and Students are trained in compliance with OSHA Blood-Borne Pathogen Regulations and that the Students and Instructors practice these standards.  District shall furnish CoxHealth and Mercy Springfield Communities proof of each Student’s and Instructor’s Hepatitis B Immunization status or a signed statement declining Hepatitis B Vaccine.
TB Screening: District shall provide proof that all Instructors and Students have tested negative for TB within one month prior to beginning the Program (Sept. 22, 2022) at Cox or Mercy.  If a Student or Instructor’s testing is positive, the District must notify Cox’s and Mercy’s Employee Health Department prior to sending the Student/Instructor to Cox or Mercy, to determine the next steps.  The student must provide evidence of 2 negative TB skin tests taken 1 week apart OR 1 negative T-spot blood test.
Hepatitis A Vaccination:  If the Program involves food service, District shall provide proof of Hepatitis A vaccination series for all Students and Instructors.  This is not required unless student is interested in dietary department.
Tdap Vaccination:  District shall provide proof of Tetanus/Diphtheria/Pertussis (Tdap) vaccination for Students and Instructors.  This must be a Tdap and NOT Dtap.
Measles, Mumps and Rubella immunity:  District shall provide laboratory evidence of all Students’ and Instructors’ serologic immunity to Rubella, Measles and Mumps, or record of Measles, Mumps, Rubella (MMR) vaccination series (2 doses at least 4 weeks apart) after one (1) year of age.
Varicella:  The District shall provide laboratory evidence of immunity to Varicella or record of Varicella vaccination series for all Instructors/Students.  The state of Missouri requires ALL students in 11th grade to receive this. CoxHealth and Mercy Lebanon Communities requires that students complete a 2 dose series or provide proof via serologic immunity (blood test) that the student has had the disease.
Meningococcal Vaccination (MCV) is now required by the state of Missouri for all 12th grade students.  One dose is required if first dose is administered at age 16 or older.  Two doses are required if first dose was administered before the age of 16.
Seasonal Influenza Vaccination:  District shall insure that all Instructors and Students receive the seasonal influenza vaccination and any other mandated flu vaccine(s) when it becomes available and before a certain cut-off date, as determined by Cox’s and Mercy’s Employee Health Department.  District will coordinate with Cox’s and Mercy’s Employee Health Department to determine the date before which Students and Instructors must receive the seasonal influenza vaccination.  District shall provide proof of each Student’s and/or Instructor’s vaccination status.
Urine screen: School shall require each Student and Instructor to submit to a twelve-panel urine drug screen prior to participating in the Program.  The urine drug must be negative and District shall provide proof of the negative drug screen upon request.
COVID-19 Vaccination: School shall require each student to submit a COVID-19 Vaccination Card prior to the participation in the Program.
2022-23 Missouri School Immunization Requirements:   All students must also provide documentation that meets the 2022-23 Missouri School Immunization Requirements

TB Test Results
You must receive a TB Test with one month prior to starting the GOCAPS Program. You will need to provide proof of 2 negative skin tests OR 1 negative T-spot blood test. Please send all test results to coordinator@gocapslakeregion.com
Drug Screening Results
Prior to starting the GOCAPS program you will need to provide proof of a 12 panel drug screening. If you choose to receive the screening from your primary care provider, please send your results to coordinator@gocapslakeregion.com
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