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SCUSD Summer of Service information and Application

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SCUSD Summer of Service information and Application Powered By Docstoc
					                                        Sacramento City Unified School District Presents….




Incoming 9th graders, don’t want to waste your summer? Want a fun way to help your community,
get ready for high school, and more?

The SCUSD Summer of Service is an exciting 6-week program that gives you the privilege of helping
out your community by providing you with service learning opportunities addressing environmental
and disaster preparedness. You’ll be able to do things like, create a community garden, create a
movie, create a robot to make change, be certified as an emergency responder and more! You will
also get the go on field trips and participate in sports and other recreation.

After completing 100 hours of service, you will be rewarded with a 500 dollar Summer of Service
Educational Award for college and 5 high school credits, not only that, but you will be more
prepared for the exciting new world of HIGH SCHOOL! During the program, you will showcase your
work using different kinds of social media.

Dates: June 21-July 30, 2010
Times: Monday – Thursday, 8:00 AM to 2:00 PM
Locations: Hiram Johnson, Luther Burbank, Kennedy, Rosemont, CK McClatchy, Health Professions,
or George Washington Carver

    If you are looking to have fun and want to meet new friends this summer, please fill out the
  application and return by June 4th to your school’s office manager or after school manager.
                           Don’t miss this once in a lifetime opportunity!

                                           Questions?
                               Estera Balarie at (916) 643-7937 or
                                   estera-balarie@sac-city.k12.ca.us.

                        Zenae Scott, Project Director at (916) 643-9430
                                zenae-scott@sac-city.k12.ca.us
                                                        SUMMER 2010
Please indicate which site your child will attend:
(Fill in circle)
        Hiram Johnson             Luther Burbank              Kennedy               Rosemont            CK McClatchy

                           Health Professions                         George Washington Carver

Student Information:

Last Name                                                            First Name

Birth Date: Month              Day           Year              Age           Gender: ! Male         Female


Address: Street number and name, plus apt. # if any:                 City

State            Zip                      Phone (day)                                    Phone (evening)


Parent/Guardian Information:
Please circle relationship: Parent         Grandparent       Other (specify): __________________

Name/Guardian (with whom student resides at residence)

Address: Street number and name, plus apt. # if any:                         City

State             Zip                      Phone (day)                                    Phone (evening)


Emergency Contact Name                                                      Phone



Medical Information:

To the best of my knowledge this child is healthy and fit to participate in the Summer of Service program:
__Yes __No, please explain _________________________________________________________________________________
Are there any activities your child cannot participate in due to physical, social, or religious reasons? ________________________
_________________________________________________________________________________________________________
Immunizations: Are they current? ___ Yes ___No
Date of last Tetanus shot __________ Regular medications ________________________________________________________
This child is currently experiencing or has recently had problems with:
__ ADD/ADHD __ Allergies __ Asthma/Inhaler My child may keep the inhaler to use it as needed: ___ Yes ___ No
__ Bee Stings __ Medicines __ Penicillin __ Restricted Diet
__ Others: Please Specify ___________________________________________________________________________________

Preference hospital in case of an emergency _____ Yes _____ No If Yes, please list: _________________________________

I understand in case of serious injury or illness, I will be notified. If it is impossible to reach me, I give permission for emergency
treatment or surgery as recommended by the attending physician. As a parent or guardian, I assume all responsibility for medical cost
incurred as the result of sickness or injury.

Parent/Guardian Signature ___________________________________________________________ Date _________________
Media Release:

        I give permission for my child to be photographed or video taped as part of his /her involvement in the SCUSD sponsored
Summer of Service. I also give permission for his/her photo and/or image to be used in publications and/or promotional material
associated with Summer of Service.

           My child may not be photographed or video taped as part of his /her involvement in the SCUSD sponsored Summer of
Service.

        Yes, my child may participate in completion of pre and post surveys associated with the Summer of Service Program. I also
give permission for my child to be able to work with social media tools and be surveyed at the end of the program.




My signature below verifies that my son/daughter has permission to participate in the Sacramento City Unified School District sponsored Summer of
Service Program. I give my consent to any medical treatment felt necessary by a doctor for the physical well being of the participant mentioned
above. I assume full responsibility for the above participant behavior and agree to pay for all damages to property or person caused by the
participants mentioned above. I agree to hold the Sacramento City Unified School District, and any of its partners, their officers, employees, agents,
servants, and volunteers harmless from any and all liability arising out of in connection with the above described activities and all liabilities
associated with any and all claims related to such activity that may be filed on behalf or for the above named minor. For the purpose of this release,
“liability” means all claims, demands, and losses, causes of action, suits or judgments of any and every kind that arise as a result of the above
described activity and resulting from any cause other than the district’s, city’s, and/or SCUSD partners gross negligence. If the participant’s behavior
interferes with the program, parents will be notified. Further disciplinary problems may result in expulsion from the program. This release shall be
continuing and shall remain in effect until termination of the program and/or revoked in writing.


Parent/Guardian Signature: _______________________________________________                    Date: ________________________________________




            •    Return to school’s office manager or after school manager by
                 June 4th.

				
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Description: SCUSD Summer of Service information and Application http://www.scusd.edu/Pages/default.aspx