THIS ADMISSIONS AGREEMENT (hereinafter the “Agreement”) is entered between Gateway Academy, LLC (hereinafter “the Academy”) and the Sponsor (hereinafter the “Sponsor”) whose name and address is/are:

Email Address:

The Academy shall be entitled to rely on the representations of either of the above-named Sponsor with respect to the Student, regardless of whether the term “Sponsor” appears in this Agreement in the singular or the plural. In consideration of the mutual promises set forth in the Agreement, the Academy and the Sponsor agree as follows:

1.  SPONSOR.  The Sponsor affirms that they are the legal parent/guardian with legal custody of (hereinafter “the Student”), whose birth date is month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , , and that they expressly desire to contract for his admission in the Academy according to the terms set forth herein.

2.  ADMISSION OF STUDENT.  The Academy accepts for admission the Student and promises to provide the following services:  room and board; routine academic supplies and services; routine therapeutic and behavioral modification services; first-aid supplies (as needed); nursing services (as needed); personal supervision; and laundry services.

3.  CONTRACT PERIOD.  This Agreement will begin month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , , and shall be renewed automatically on a month-to-month basis, unless either party terminates this Agreement by its terms.  In the event the Student attains the age of eighteen (18) years prior to such termination, then his enrollment shall end on his eighteenth (18th) birthday.  A student may continue enrollment after his eighteenth (18th) birthday with both the written agreement of Sponsor, and the Student’s written agreement granting conservatorship to the Academy.  All other terms of this Agreement shall apply during any period of conservatorship.

4.  FINANCIAL PROVISION.

a.    DAILY RATE.  The Academy only accepts US currency.  The Sponsor agrees to make all payments set forth in this Agreement in US currency.  The daily rate for services at Gateway Academy, as described under Section 2, is $450.00 (four hundred fifty dollars).  In certain cases, the Academy agrees to an underinsured daily rate of $310.00 (three hundred ten dollars).  The uninsured daily rate of $310.00 is available to those sponsors whose personal insurance policy does not cover the services offered by the Academy.  Such Underinsured Daily Rate Request is attached hereto as Attachment ‘A’. 

b.    PAYMENT.  The Sponsor shall be billed on a monthly basis.  Payment is due the FIRST (1st) DAY of each month for the calendar month.  The Sponsor acknowledges that the Academy does not provide services for a non-paying Student.  Non-paying Students shall be subject to immediate discharge beginning the SEVENTH (7th) DAY of the calendar month in which payment was not received by the Academy.  The Sponsor agrees to pay the daily rate for services up and through the final date of discharge, including all days the Student is away from the Academy but is still admitted to the Academy.  The Academy will make reasonable attempts to successfully transition the Student pursuant to a discharge under this subsection (b).

c.    BREAKDOWN OF DAILY RATE.  The Academy does not bill Sponsor separately for services provided by the Academy.  The Academy provides the following daily rate breakdown as a courtesy only, to be used by Sponsor for purposes of tax deductions, school funding, insurance plans, or other third party payers who desire to pay a specific portion of the services offered by the Academy.

The Academy does not provide outpatient or itemized billing, an itemized breakdown based on a chart review, or the completion of Health Insurance Claim Forms.  The Academy does not provide copies of a Student’s chart for purposes of outpatient billing. 

d.    INITIAL PAYMENT AND PAYMENT SCHEDULE (Insured Daily Rate).  Based on an insured daily rate of $450.00, an initial placement payment of $20,640.00 shall be paid upon admission as follows:

e.    INITIAL PAYMENT AND PAYMENT SCHEDULE (Underinsured Daily Rate).  Based on an underinsured daily rate of $310.00, an initial placement payment of $16,440.00 shall be paid upon admission as follows:

f.    ADDITIONAL COSTS AND EXPENSES.  In addition to the daily rate, the Sponsor agrees to pay for any and all additional necessary expenses incurred for the use and benefit of the Student during his enrollment at the Academy, including, but not limited to:  medical (including medication and medication checks); dental and laboratory; psychological and psychiatric services and testing; airline, bus line or commercial travel; postal costs; telephone calls, special academic tutoring and supplies, and special recreational products and services.  The Sponsor understands and acknowledges that some expenses may be necessary on an emergency basis, and that the Sponsor may not receive prior notice of such expenditures.  Short of an emergency situation (as determined solely by the Academy), the Academy agrees to obtain prior approval from the Sponsor of the above-referenced expenditures.  Such expenditures shall be billed to the Sponsor as they arise, and shall be immediately due and payable upon receipt of such bill.

g.    INSURANCE BILLING.  The Academy provides courtesy billing to insurance companies in the amount of its full daily rate. The Sponsor agrees to pay the daily rate in advance of services rendered by the Academy. In the event the Sponsor has paid in advance for Academy services, the Academy agrees to reimburse the Sponsor for insurance benefits later received.  The Sponsor acknowledges that the Academy does not automatically bill insurance companies, check benefits, or otherwise assume any responsibility for collection of insurance reimbursement unless specifically requested to do so by the policyholder.   The Academy will not extend credit to the Sponsor in anticipation of insurance benefits.  The Sponsor agrees to sign an Assignment of Insurance Benefits document simultaneous with this Admission Agreement.  Such Assignment of Insurance Benefits is attached hereto as Attachment ‘B’. 

h.    BANK SERVICE FEES.  Sponsor agrees to pay a fee in the amount of three (3) percent of all amounts that are paid under this Agreement by credit or debit card.  For convenience purposes, the Sponsor may sign a Credit Card Consent document simultaneous with this Admission Agreement that allows the Academy to keep a credit or debit card on file.  Such Credit Card Consent is attached hereto as Attachment ‘C’. 

i.    FINANCIAL CREDIT.  Pursuant to this Agreement, the Sponsor may have a financial credit with the Academy at the time the Student is discharged.  The Sponsor agrees that any and all financial credits shall be paid to the Sponsor forty-five (45) calendar days following the Student’s discharge from the Academy.

5.  DISCHARGE AND TERMINATION OF AGREEMENT. 

a.    MUTUAL AGREEMENT FOR DISCHARGE:  A student may be discharged at any time by the mutual agreement of the Academy and of the Sponsor.  Sponsor agrees to pay the daily rate for services up and through the final date of discharge.

b.    SPONSOR’S SOLE REQUEST FOR DISCHARGE: A student may be discharged solely at the Sponsor’s written request.  Sponsor agrees to provide the Academy with a minimum of fourteen (14) days notice prior to Sponsor’s request for discharge.  Sponsor agrees to pay the daily rate for services up and through the final date of discharge, or for a minimum of fourteen (14) days from the date the Academy received such written request, whichever is greatest.

c.    THE ACADEMY’S SOLE REQUEST FOR DISCHARGE:  A student may be discharged at any time by the Academy due to: the Student’s illegal and/or criminal behavior; health and safety reasons; a natural disaster; or other emergency situation that renders Student’s continued enrollment at the Academy physically or clinically unsound.  The Academy agrees to provide the Sponsor with a minimum of twenty-four (24) hours notice prior to the Academy’s request for discharge.  The Sponsor agrees to pay the daily rate for services up and through the final date of discharge.  The Academy will make reasonable attempts to successfully transition the Student pursuant to a discharge under this subsection (c).  In the event the Student commits a crime while enrolled at the Academy, the Academy reserves the right to have local authorities involved in the matter.

6.  LIABILITY:  Sponsor recognizes, understand and acknowledge that the Academy programs and activities have inherent risk of emotional or physical injury.  Sponsor agrees to hold harmless the Academy for injuries, illnesses, or other damages occurring to the Student during the term of his admission that result from the Student’s participation (on or off the Academy property or during transportation) in programs and activities of the Academy.  The Academy assumes no liability for such injuries, illnesses or other damages.  Sponsor also recognizes, understands and acknowledges that the Academy is not liable financially or otherwise for loss, damage, or theft of any of the Student’s property. 

7.  ATTORNEY’S FEES.  Sponsor agrees to pay the cost of collection of any amounts due under this Agreement, including reasonable attorney’s fees at the rate of thirty-five (35) percent of the balance assigned.
                                                      
8.  AGREEMENT TO PAY REGARDLESS OF INSURANCE OR OTHER THIRD PARTY PAYEE.  The Academy and the Sponsor may agree that the Academy should pursue insurance benefits or other third party payee for the Student for medical services rendered by the Academy.  The Sponsor agrees to pay the Academy all amounts due under this agreement on the date they are due regardless of possible insurance or third party payee benefits.  The Academy shall refund the Sponsor any amounts paid under this Agreement that are later paid by insurance or other third party payee.

In the event the Academy pursues insurance or third party payee benefits for the Student, all such benefits shall be paid to the Academy and the Academy shall reimburse the Sponsor for amounts paid by Sponsor that are specifically covered by such proceeds.  Nothing in this Agreement shall be construed to be an obligation by the Academy to pursue any such benefit recovery.  

9.  RELEASE OF RECORDS.  The Academy shall release the Student’s transcript and records to other facilities upon the specific request of the Sponsor, provided, however, that transcripts and records of academic credits shall not be released until all amounts owing the Academy under this Agreement at the time of the request shall be paid in full.

10.  POWER OF ATTORNEY.  The Sponsor agrees to sign a Power of Attorney document simultaneous with this Admission Agreement.  The Sponsor shall appoint the Academy as the Student’s lawful attorney for the purpose of providing custodial care and educational and clinical services during his enrollment at the Academy.  Such Power of Attorney is attached hereto as Attachment ‘D’.  In the event such Power of Attorney expires, and the Student is still enrolled at the Academy, the Sponsor agrees to sign an additional Power of Attorney for duration of the Student’s enrollment at the Academy.

11.  CHOICE OF JURISIDCTION, LAW, AND OTHER MATTERS.  Sponsor agrees to be subject to jurisdiction of the Utah Courts in any dispute between the Parties to this Agreement.  The Parties agree that this Agreement constitutes a business transaction and is subject to the provisions of Title 78, Chapter 27, Section 24, of the Utah Code Annotated 1953, as amended.  The Sponsor agrees that Utah law shall govern this Agreement.  Failure of either Party to enforce any term or provision of this Agreement shall not constitute or be construed as a waiver of such term or provision or the right to enforce it.  If any provision of this Agreement is construed to be overbroad as written, the remaining provisions shall remain enforceable according to applicable law.  Sponsor has read this Agreement and understands and assents to its provisions.  This Agreement constitutes the entire Agreement between the Parties except as may be noted by the attached Attachments.

Underinsured Daily Rate Request
Attachment ‘A’

I/We, the undersigned, hereby request an underinsured “daily rate” for Gateway Academy, LLC (the “Academy”) in the amount of $310.00.  I/We acknowledge that the insured “daily rate” for the Academy is $450.00. 

As set forth in Section 2 of the Gateway Academy, LLC Admissions Agreement, the “daily rate” covers the cost of room and board; routine academic supplies and services; routine therapeutic and behavioral modification services; first-aid supplies (as needed); nursing services (as needed); personal supervision; and laundry services.

Assignment of Insurance Benefits
Attachment ‘B’ - 1

Please complete a separate form for each medical or dental insurer.
Please attach a copy of both the front and back of your insurance card.

Student Name Admit Date month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,
Insured Name Insured SS# --
Insured DOB month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , Insurance Co.
Insurance Co. Address
Insurance Co. Phone #
Policy # Group #
Insured Employer
Employer's Address
Coverage
Pharmacy Card#
Please Choose One: Primary Insurer   or   Secondary Insurer

For the purpose of paying all or part of monies owing to Gateway Academy, LLC (hereinafter the “Academy”) for services it has or will render to the above Student, the undersigned hereby irrevocably assigns to the Academy any benefit payments payable for the benefit of said Student by the above insurance company or companies and all rights and interest in said policy but only to the extent necessary to pay the Academy in full.  Undersigned hereby grants to the Academy the right to bill the above insurance company at its full retail or contract rate.  Undersigned acknowledges and agrees, however, that the Academy is not obligated or required to bill the insurance company.  Undersigned agrees to remain liable for all amounts owing to the Academy as a result of rendering services to the Student, regardless of any insurance coverage or benefits available to such Student, and undersigned’s liability will only be reduced by the amount of benefit payments received by the Academy from the above referenced insurer.  Notwithstanding the above, undersigned’s liability will not be reduced until the Academy has collected its full retail or contract rate.  Undersigned understands that the nature of Student’s disability may be such that no benefit payments will be payable under the policy specified above.  The Academy verifies insurance and bills insurance companies as a courtesy to the undersigned, and is not responsible for any misinformation received from the insurance company regarding benefits.  It is the responsibility of the insured to understand his/her benefits and allowable coverage under the policy.  To the extent necessary to determine liability for payment and to obtain reimbursement, the undersigned authorizes the Academy to disclose information from the treatment received to persons or corporations that may be liable for all or any portion of the facility’s charges, including but not limited to insurance companies, health plans and Workers’ Compensation carriers.  Such information may include psychiatric evaluations, diagnoses, history and physical examination reports, program notes, physician orders and laboratory results, as well as school information.  Such records may contain psychiatric or substance abuse information.

Credit Card Consent
Attachment ‘C’

I/We, the undersigned (the “Sponsor”), authorize Gateway Academy, LLC (the “Academy”), to maintain my credit card on file to pay for services rendered (as set forth in the accompanying Admission Agreement) on behalf of (the “Student”).

The Academy agrees to receive prior approval to use the above-reference card for any amount in excess of $.
The Sponsor agrees pay a fee in the amount of three (3) percent of all amounts that are paid by credit or debit card.

Cardholder Name
Billing Address

Visa     Mastercard     Discover     Check/Debit Card
Credit Card Number Expr. Date / Security Code

Power of Attorney
Attachment ‘D’

KNOW ALL PERSONS BY THESE PRESENT that I/we, the undersigned, appoint Gateway Academy, LLC, a Utah Company (the “Academy”), to be the true and lawful attorney-in-fact for (the “Student”), for the purposes of providing custodial care, educational, and clinical services.

Without limiting or qualifying the general Power of Attorney delegated and assigned in the paragraph above, the undersigned specifically grants the Academy the following powers.

1. To provide or obtain any medical treatment and hospital care, and to authorize a physician to perform any and all procedures that may appear to be medically necessary for the well-being of the Student;
2. To discipline the Student within the bounds of Utah law;
3. To physically restrain the Student within the bounds of Utah law in the event he becomes a danger to himself, to others, or to the surrounding facilities; and
4. To provide any and all services deemed clinically and educationally appropriate for the Student as determined by the Academy and its personnel.

The Power of Attorney shall be effective through and until six (6) months from the date of admission of the Student to the Academy, through and including his final day of admission to the Academy.

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