City Summer Internship 2017
Apprentice Learning’s City Summer Internship is a paid internship program for rising ninth grade students to engage in real-world learning in STEM fields. Workplaces around Boston welcome interns and put them to work, so that they may observe the adults around them, test their communication skills and build on newfound professional skills with a real sense of what these mean in the workplace.
Email address
Program Application
Please note the deadline for the program application is May 19, 2017
Student Information
First Name
First and last name
Your answer
Last Name
Your answer
Date of Birth
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Student email address
Your answer
Student cell phone number
Your answer
Current School
Your answer
Current Grade Level
How did you hear about Apprentice Learning's City Summer Internship?
Your answer
Parent/Guardian 1
Last Name
Your answer
First Name
Your answer
Preferred Phone Number
Your answer
Street Address (only if different from student address above)
Your answer
Email Address
Your answer
Parent/Guardian 2 Information
Last Name
Your answer
First Name
Your answer
Preferred Phone Number
Your answer
Street Address (only if different from student address above)
Your answer
In addition to the Parent(s)/Guardian(s) listed above, the following adults are authorized to pick up my child.
If, during the program, an adult other than those listed below is picking up a child, there must be written authorization from a parent/guardian. To ensure the safety of our students, Apprentice Learning staff may require photo identification of any person picking up a student.
Last Name
Your answer
First Name
Your answer
Preferred Phone
Your answer
Street Address (only if different from student address above)
Your answer
Emergency Contact: the above would be available to pick up a sick child during program hours
Please describe any custodial issues with the family of which Apprentice Learning Staff should be aware:
Your answer
Health History
Please select and describe any allergies:
Please explain allergy, reaction, and severity.
Your answer
Please list medications for allergies
If medications are to be administered at the program, the medication administration portion of this application must be completed.
Your answer
Please check the medications and other products which may be administered to your child, if needed.
My child will be bringing medications (this includes over-the-counter medicine) to the program
Immunization history and physical exam requirements
Massachusetts requires a Certificate of Immunization for all children and staff. Please provide a copy from your child's school or doctor's office.
Apprentice Learning requires proof of a physical examination, conducted within the past year, confirming the child is fit to participate in program activities. Please provide a copy from your child's doctor's office
Please list any physical, mental or psychological conditions (such as ADD, ADHD, Diabetes, etc.) requiring medication, treatment, or restrictions while in the program.
Your answer
Does your child take any prescription or over the counter medication at home?
Describe any specific activities in which your child cannot participate.
Your answer
Please list any dietary modifications or restrictions, including food allergies.
Your answer
Physician/Pediatrician Name/Office
Your answer
Phone Number
Your answer
Insurance Carrier
Your answer
Insurance Policy Holder Name
Your answer
Member #
Your answer
Is there anything you would like us to know about your child that will help her have a successful experience?
Your answer
Medications, Inhaler and EpiPen Administration
This form must be completed for any or all medications that will be brought and administered at Apprentice Learning. All medications will be kept with the Director. Please fill out the following information completely.
Prescribed Medications Must:
- Have a pharmacy label with the Rx number, name of the medication, and child's name
- Include dosage and directions for use
Non-Prescription Medications Must:
- Be in their original containers
- Be clearly labeled with the child's name
- Include directions for us
Medication
Name of Medication
Your answer
Why is this medication taken?
Your answer
Days taken
Times taken (please, be specific)
Your answer
Dosage
Your answer
Are there any additional notes or instructions for this medication?
Your answer
Complete this section if your child has asthma
Will your child be taking an inhaler or other asthma medication to the program?
If medications are to be administered at the program, the medication administration portion of this application must be completed.
Inhaler
Location of inhaler at Apprentice Learning
Who may administer inhaler?
EpiPen
Location of EpiPen at Apprentice Learning
Who may administer EpiPen?
I hereby give permission for Apprentice Learning to administer the following medications to my child during her program attendance.
Your answer
Date
MM
/
DD
/
YYYY
Authorizations
Accuracy of Information
This health history is correct so far as I know and the person herein described has permission to engage in all program activities except as noted.
Authorization for Treatment
In case of an emergency, I authorize Apprentice Learning to administer first aid and to transport my child to the nearest hospital emergency room, and to order x-rays, routine tests and treatment; and to release any records necessary for insurance purposes. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the program director or his/her designee to secure and administer treatment, including hospitalization for the person named above, I understand that all medical bills for services are my responsibility. This completed form may be photocopied for field trips.
Acknowledgement of Risk and Waiver
I hereby release and discharge and agree to indemnify and hold harmless Apprentice Learning and it's officers, directors, members, agents, employees, volunteers and any other persons or entities on its behalf against all claims, demands and causes of actions whatsoever, either in law or equity relating to or arising from any medical treatment, recommendation, transportation or administration or any lack thereof.
Parent/Guardian Signature
Your answer
Date
MM
/
DD
/
YYYY
Enrollment Agreement
Registration/Confirmation
In order for our child to be considered for enrollment, Apprentice Learning must receive:
Immunization History and Physical Examination
Massachusetts law requires each child to have a current copy of Certificate of Immunization prior to the first day of City Summer Internship. I understand that my child will not be permission to participate in the program until the following additional paperwork has been completed and received by June 30, 2017
Media and Liability Release
I give Apprentice Learning and its partners permission to use my child's image or statements in its educational or promotional efforts. I understand that Apprentice Learning and its partners may reproduce and distribute such material through press releases, print ads, direct-mail, video, or online. By signing this form, I release Apprentice Learning, and participating organizations, and any of their employees or agents acting on behalf of each entity, from any and all liability and/or damages, for any personal injury, or property damage suffered by my child, or for personal injury or property damage suffered by third parties as a result of my child's actions, while participating in this program. I have read this form and understand and accepts its terms.
Dismissal
I understand that Apprentice Learning reserves the right to dismiss any child whose behavior interferes with the rights and safety of others. In such cases no refunds will be given.
Programs and Activities
I understand and certify that my child's participation in the Apprentice Learning program and its activities is completely voluntary and that I have become familiar with the program activities in which my child may participate as described on the website or in the brochure or information packet.
My signature below indicates I have read and understand the policies above. I hereby grant permission for my child to participate in all planned Apprentice Learning programs and activities, including any field trips.
Your answer
Thank you for completing the City Summer Internship Application. A staff member will be in contact with you soon to let you know the status of your application. If you should have any questions about the program, please call or email Nina Fish:
Apprentice Learning
20 Child Street
Jamaica Plain, MA 02130
www.apprenticelearning.org
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms