Lummi Nation Employment Application Form - PDF by ugc12518

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									                                                    K-12




A Message from Our Director of Behavioral Health:
                               Lummi Nation




          2010 Summer School Application
           Return Completed Application to YESS Department

This Application Belongs To:                                         DOB:

Which Program, please check one:   Head Start   Summer School (K-8)         Kids 1st (9-12)

Last School Attended:                                    Grade Completed:

                                                     Please submit a copy of each:
                                                           CIB/Tribal Enrollment

                                                           Social Security Card

                                                           Insurance/Medicaid Card

                                                           Official Transcripts (Kids 1st)

                                                           ID Card (Kids 1st)
                                                       Verify Completely Filled Out &
                                                         Signatures Are Necessary!


                                   Office Use Only
Reviewed By:                                                 Date:

Needs to Complete:

Approved By:
                                                                               All Stared Areas Must Have Signatures!!!


                           Lummi Nation K-12 Grade
                             July 6th-August 5th 2010
                           Summer School Application
Legal Name of Student Applying:                                                      Grade Completed       Social Security #:
Last Name                       First Name           MI              Age             as of June 2010:



Mailing Address:                                                   Home #                         Cell #                   Message #



Student Birth Date                   Gender                        Birthplace:          City        State                 County
(Month/Day/Year)



Is Your Child Enrolled in a Federally Recognized Tribe?              yes        no
If yes, Name of Tribe:                                                                         Tribal Enrollment No:
Student Lives With:   Both Parents    Father Only      Mother Only            Grandparents     Father/Stepmother          Mother/Stepfather
                      Stepfather/Stepmother            Guardian               Self              Agency                    Other ________________
Parent/Guardian Name                      Address                                                 Home Phone Number           Work/Message Number




Parent/Guardian Name                      Address (if different than above)                       Home Phone (if              Work/Message Number
                                                                                                  different than above)




Emergency Contact Person #1               Address                                                 Home Phone Number           Work/Message Number




Emergency Contact Person #2               Address                                                 Home Phone Number           Work/Message Number




Please List any Medical Conditions:       Currently on any Medications?                           Special Diet? Be specific:
Child Name _________________________      Child Name __________________________                   Child Name: __________________________

Condition ___________________________     Medication___________________________                   Dietary Needs:_________________________




  Please be advised ALL Summer School Applications need to
  be COMPLETELY filled out and SIGNED in order to be
  processed in a timely manner!
  Incomplete applications will only delay the                                                                                      process
  application, and may affect the order it was received.
  Thank you for your attention to detail!
                                                                     2
E     In the event I/We cannot be contacted, I/We, the undersigned parent or legal guardian of,         Chronic Illnesses?
      Child 1_________________________ hereby consent and give permission to the Lummi
M     Nation YESS Department and Lummi Nation School Summer High School Program, Kids                   Child Name:________________________
E     First, and Day Camp to render and authorize emergency medical treatment, including
R     hospitalization and medical procedures deemed necessary by a physician.                           Illness:_____________________________
G     If I cannot be reached please contact:
E
N     Name:___________________________ Relationship to Child:_____________________
C     Contact #_____________________________
Y
      Name:___________________________ Relationship to Child:_____________________
M     Contact #_____________________________
E
D     Name:___________________________ Relationship to Child:_____________________
I     Contact #_____________________________
C
A     Date of Last Tetanus Booster: (Please list all children)
      __________________________________________________________________________
L     __________________________________________________________________________
      __________________________________________________________________________
R
      Primary Physician:___________________________ Contact #__________________
E
L     By this document, I hereby release the Lummi Nation School, the YESS Department, its
E     employees, and volunteers from any and all liability, claims, and/or causes of action arising
      out of, or in any way relating to the provision of necessary medical treatment for
A
S     Parent/Guardian Signature:________________________________________________
E
      Date:________________________________
Previous School(s) Attended                     Address                                               Phone Number           Fax Number
Child Name/School Attended:                        ______________________________________          ________________          _______________
_________________________________                  ______________________________________           _______________          _______________
_________________________________                  ______________________________________          ________________          _______________
_________________________________                  ______________________________________          ________________          _______________
_________________________________                  ______________________________________          ________________          _______________
_________________________________                  ______________________________________
Any Court Orders in Effect?           yes      no                      Has Your Child Ever Been Retained?
(If yes, please attach a copy of the court order.)                         yes     no
                                                                       If yes, Please list name and Grade Retained?


Does your child have a current Individual Education Plan (IEP)?           yes       no (If Yes please list names)

Photograph Information      Yes, my child may be photographed/video for school purposes only.         No, my child may not be photographed.




                                                                         3
                                               FIELD TRIP RELEASE

I hereby authorize my Child:________________________________________________ to participate in the scheduled afternoon field
trips provided by Lummi Nation School, the YESS Department, Kids First, Day Camp and the Summer High School Program.

:________________________________________________                                ____________________________________________
Parent/Guardian Signature                                                              Date
                                                 Transcript Release

                                                      REQUEST FOR TRANSFER
                                        OF OFFICIAL TRANSCRIPTS and/or ATTENDANCE REPORTS

To:


Attn:             Registrar___________


Child Name:__________________________________________ SSN:_______________________________ DOB:_______________________

         I hereby give my permission to the above named programs to forward all official transcripts and/or attendance records to the Lummi
Nation School Summer School Programs. I understand that photocopies of these documents will be provided to the summer school programs
when needed, and I will hold harmless my previous school district for this transfer of records.

Student Signature:________________________________________________Date:__________________________
(If over 18 years of age)
Parent /Guardian Signature:________________________________________________ Date
(If over 18 years of age)
OFFICE USE ONLY

Program Requesting Information:

Program Name:_____________________________________________                         Address:____________________________
                                                                                            ____________________________
                                                                                   Fax:     ____________________________

Program Managers Signature:__________________________________                      Date:     ___________________________



I certify that the above information provided is true to the best of my knowledge. I am also aware that the information is
subject to verification and that falsification of the application shall be grounds for termination from the program. I
understand that I have to provide documents to support this application.
Participant Signature:                                                                   Date:
(If applying for Kids 1st Employment)
Child 1___________________________________________________________________

Parent/Guardian Signature:                                                                     Date:

________________________________________________
Staff Signature:                                                                               Date:




                                                                     4
                                SUMMER SCHOOL 2010
      Lummi Nation K-12 School/YESS/Kids 1st / Day Camp/High School Summer Program


                              Ethics & Code of Conduct Policy
    1. The possession, use and/or consumption of alcohol, tobacco or illegal drugs are not
        allowed during any sponsored program or activity.
    2. The program will not tolerate any form of physical or verbal abuse on the part of the
        program participates or instructors. This includes any markings (i.e. hickies or offensive
        tattoos)
    3. The program will encourage participants to respect” Personal Space” of self and others.
        Zero tolerance of inappropriate behaviors is cause for expulsion of individual offenders.
    4. The program will not tolerate possession of weapons of any sort.
    5. The program will enforce a dress code. Appropriate attire is required for participants.
        Cleanliness and neat appearance is expected of all participants and instructors.
    6. The program will not tolerate the wearing of “colors”. Bandannas may only be worn by
        those who are required to do so for cultural reasons.
    7. ATTENDANCE: you are required to be in class everyday in order to receive your
        stipend for that work. Attendance sheets are reviewed weekly and approved by
        Instructors on Fridays. This is Non-Negotiable. In Addition, attendance is monitored
        regularly by Kids First Staff. Falsification of attendance is grounds for immediate
        termination
    8. JOB PLACEMENT: participants of the Kids 1st Program who will be receiving a
        stipend will be required to fulfill job duties as assigned by supervisor, will be required to
        complete the full work day as outlined by supervisor and will be expected to keep a daily
        log of duties completed and signed off by supervisor daily. (Logs will be provided)
        Falsification of daily logs and timekeeping records will be grounds for immediate
        termination.
Failure to comply with any of the above non-negotiable policies will be cause for immediate
suspension from the program. If you are suspended form the program you will not receive your
stipend until the completion of the summer school program.

I have read the above policies and understand my responsibility to fellow participants, the Kids
First Program and I will abide by these policies while participating in the Summer School
Program

________________________________________________       ______________________
Signature of Participant                                     Date

________________________________________________       ______________________
Parent/Guardian Signature                                    Date




                                                   5
                                           SUMMER SCHOOL 2010

         Lummi Nation K-12 School/YESS/Kids 1st /Day Camp/High School Summer Program


                              DRUG & ALCOHOL POLICY CONTRACT

I agree to follow the Summer School Program Drug & Alcohol Free Policy while participating in
the Summer School Program, by adhering to the following Policies:

Please have all participants initial

__ __ __ __ __ 1.) To abstain from Drugs & Alcohol during my employment

__ __ __ __ __ 2.) I understand that the Summer School Program is to support and promote
                   my effort in making healthy choices.

__ __ __ __ __ 3.) I will not expose myself to unsafe environments and lifestyles.

__ __ __ __ __ 4.) I understand the “Zero Tolerance” of the Summer School Program and will
                    abide by this policy. Random UA’s may be utilized to ensure the
                    integrity of this program

__ __ __ __ __ 5.) I also agree to talk to staff if I am having problems with substance abuse
                    to set up a plan of assistance to be successful.


I am fully aware of the support and opportunity the Lummi Nation collaborating programs are
giving me to obtain the skills needed to enter into the workforce and further my education.

:________________________________________________       ______________________
Signature of Participant                                      Date


:________________________________________________       ______________________
Parent/Guardian Signature                                     Date




                                       LUMMI NATION YESS DEPARTMENT


                                                    6
                                         Pre-School
                                      K to 12th Grades
                               Emergency Medical Release Form


CONSENT TO MEDICAL CARE AND TREATMENT OF MINOR CHILD
In the event I/We cannot be contacted, I/We, the undersigned parent or legal guardian of
__________________________________, hereby consent and give permission to the Lummi
Nation YESS Department to render and authorize emergency medical treatment, including
hospitalization and medical procedures deemed necessary by a physician, to
__________________________________.

By this document, I hereby release the Lummi Nation YESS Department, its employees, and
volunteers from any and all liability, claims, and/or causes of action arising out of, or in any way
relating to the provision of necessary medical treatment for
____________________________________________________________.

________________________________________________________________________________
Parent or Guardian Signature                    Date
______________________________________________________________________
Date of Birth                                   Home Phone
______________________________________________________________________
Known Allergies (including drug reaction)
______________________________________________________________________
Special Diet (be specific)
______________________________________________________________________
Chronic Illnesses
______________________________________________________________________
Medications in Use
______________________________________________________________________
Child’s Physician                               Phone Number
_____________________________________________________________________
Medical Insurance Provider
_____________________________________________________________________
Subscriber’s Name                               Policy Number




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