Pittsburgh Public Schools 2008 Summer 9th Grade Nation Transition

							                                     Pittsburgh Public Schools
                                  2008 Summer 9th Grade Nation
                                  Transition Program Application
  To Enroll: Please return the completed application and forms for Camp Guyasuta to the Office of High School
             Excellence, Pittsburgh Board of Public Education, 341 S. Bellefield Avenue, Pittsburgh, PA 15213,
             for enrollment into the program.

Student’s Name:                                                       Age:                               Birth Date:

School Attended in 2007–08: _______________________________________                                  * Promoted to 9th Grade: □ Yes   □ No
High School for 2008-09 School Year: (For assistance, contact your student’s school counselor)
  □ Pittsburgh Allderdice □ Pittsburgh Brashear □ Pittsburgh CAPA □ Pittsburgh Carrick □ Pittsburgh Frick IS/IS
             □ Pittsburgh Langley □ Pittsburgh McNaugher □ Pittsburgh Peabody □ Pittsburgh Perry
                          □ University Prep at Milliones Facility □ Pittsburgh Westinghouse
Student’s Address:                                                                                       Home Phone:
                      House Number/Street Name                                       Zip Code

Parent’s/Guardian’s Name:                                                                                Home Phone:

Work Phone:                                                                 Pager/Cell Phone:

Parent’s/Guardian’s E-mail address:

Emergency Contact Person:                                                                      Relationship:

Emergency Contact Phone:

Does your student currently receive Special Education services?                □ Yes □ No
Does your student take any medications on a regular basis?                     □ Yes □ No
Please list medications taken by your student:
_____________________________________________________________

Please list any allergies your student has:
_________________________________________________________________
Does your student have any dietary restrictions?               □ Yes □ No
If yes, please list the foods he/she is not permitted to have: _________________________________________________

Please list any physical restriction(s) or other condition(s) of which we should be aware:
________________________________________________________________________________________________

   Parent Permission for Attendance at 2008 Summer 9th Grade Nation Transition Program
I give permission for my student ______________________________________________________________ to attend.
                                         (Student’s Name).
Parent’s Signature: __________________________________________________________                                   Date:




                                           We are an equal rights and opportunity school district
            Pittsburgh Public Schools
            Mark Roosevelt, Superintendent of Schools

            341 South Bellefield Avenue | Pittsburgh, PA 15213-3516
            Parent Hotline: 412-622-7920 | superintendentoffice@pghboe.net | www.pps.k12.pa.us



                                              MEDIA RELEASE FORM 
 
Dear Parent/Guardian:   
 
        Students who participate in the 9th Grade Nation 2008 Summer Transition Program may be 
photographed or interviewed by representatives of the media and/or the Pittsburgh Public Schools Division 
of Communications and Marketing to provide news coverage of project activities or to produce public 
relations and marketing materials such as newsletters, brochures and videos about the 9th Grade Nation. 

        If you agree to have your student photographed and/or interviewed, please sign and date the form 
below.   
         
                           
 
 
I, _____________________________________________, parent/guardian of 
                        Parent/Guardian’s name  
____________________________________________________, agree to have my 
                        Student’s name 
 
son/daughter photographed and/or interviewed by representatives of the media and/or Pittsburgh Public 
Schools Division of Communications and Marketing during participation in the 9th Grade Nation 2008 Summer 
Transition Program.  
 
______________________                   ________________________________________________________ 
            Date                                                   Signature 

 
Greater Pittsburgh Council                                                                 Boy Scouts of America 
                                           MEDICAL INFORMATION 
                                      USE FOR NON‐SCOUT PARTICIPANTS 
 
Name ________________________________________________________________________ 
            First                   Middle Initial           Last 
 
Telephone (            ) __________________              (           ) ____________________________ 
                           Home                                           Work/Cell 
 
Personal physician __________________________________ (            ) ___________________ 
                           Name                                          Phone 
 
In case of emergency, please contact __________________________   (          ) ____________ 
                                               Name                                       Phone 
Special dietary considerations 
____________________________________________________________________________________________
________________________________________________________________ 
 
List known allergies ____________________________________________________________ 
 
List required medications 
____________________________________________________________________________________________
________________________________________________________________ 
If you are allergic to be stings, do you have a bee sting kit?  Yes ______      No ______ 
 
Do you wear contact lenses?  ________          Are you pregnant? _________ 
 
Have you had or do you have (circle if yes)  Heart Attack  Diabetes             Asthma   
 
Angina          Epilepsy        Chest Pains      Drug Reactions     High Blood Pressure    Heart Murmur 
 
If you answered “yes” to any of the above, explain and include date 
____________________________________________________________________________________________
________________________________________________________________ 
 
Do you have any other medical conditions that we should be aware of? 
____________________________________________________________________________________________
________________________________________________________________ 
 
I am not under the influence of any chemical substance, including alcohol.  Understanding that any physical activity 
involves a risk of injury, I understand that my participation in the Greater Pittsburgh Council’s climbing/rappelling 
program is entirely voluntary.  I release the greater Pittsburgh Council, Boy Scouts of America, its employees, and staff 
from any claims or liability arising out of my participation.  This release does not, however, apply to any harm caused by 
negligence or willful misconduct of the Greater Pittsburgh Council, Boy Scouts of America, or its employees. 
 
Please print clearly 
Name ________________________________ Course/Company _________________________   
Participant’s signature * __________________________ Date __________________________ 
*If participant is under 18 years of age, a parent or guardian must also sign below 
 
Signature of parent or guardian _____________________________________ Date __________________________ 
Greater Pittsburgh Council                                                                    Boy Scouts of America 
 
                             C.O.P.E. (Challenging Outdoor Personal Experience) 
                                                                   
HOLD HARMLESS/RELEASE AGREEMENT 
 
I understand that use of the camp facilities on _____________ (date) owned by the Greater Pittsburgh Council, Boy Scouts of 
America involves a certain degree of risk that could result in injury or death.  In consideration of the benefits to be derived and after 
carefully considering the risk involved and in view of the fact that the Boy Scouts of America is a not‐for‐profit organization, I 
hereby release and hold harmless, and waive all claims I may have against Boy Scouts of America, Greater Pittsburgh Council, 
activity coordinators, all employees, volunteers, or other organizations associated with the Summer 2008 9th Grade Nation 
Transition Program (activity). This agreement does not, however, apply to any harm caused by negligence or willful misconduct of 
the Greater Pittsburgh Council, Boy Scouts of America, or its employees. 
 
__________________________________                                         ________________________ 
Student Signature                                                                 Date 
 
_________________________________                                          ________________________ 
Parent of Guardian’s Signature                                                    Date 
 
 
THE FULL VALUE CONTRACT 
This contract is in agreement between you and the rest of your group to perform the following: 
 
1. I will give an honest effort in all activities                  2. I  will  accept  my  role  within  the  group  during  any 
         a. I  will  follow  all  rules,  even  when  the  going      activities  in  a  manner  that  will  encourage  group 
             gets tough.                                              success.  
         b. I will give all challenges my best shot.                             a. I  agree  to  participate  positively  in  one 
         c. I will keep an accurate and honest account of                            of the following roles: 
             my feelings and reactions to the activities.                              i. Leader 
         d. I agree to follow all safety and group behavior                           ii. Follower 
             guidelines.                                                             iii. Information Seeker 
                                                                                     iv. Supporter 
                                                                                      v. Positive Feedback Person   
3. I will share in group success as well as failure                4. I agree to confront and award group members when 
         a. I  agree  to  work  together  to  achieve  both           needed in regard to their behavior and/or attitude 
             group and individual goals.                                    a. I will give and receive honest feedback. 
         b. I  am  responsible  for  other  group  members’   
             safety and behavior. 
         c. I  will  encourage  others  in  the  group  to  feel 
             important. 
         d. I will value others’ ideas and feelings. 
 
I understand the full value contract. I agree with its principles and will do my best to abide by it. 
 
__________________________________                                         ________________________ 
Student Signature                                                                   Date 
 
_________________________________                                          ________________________ 
Parent of Guardian’s Signature                                                      Date