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 email@example.com. Zenae Scott, Project Director at (916) 643-9430 firstname.lastname@example.org 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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