YUKON-KOYUKUK SCHOOL DISTRICT

Yukon-Koyukuk School District 2017 Spring Crossing Our Bridges Health Academy Student Application & Medical Consent
Name:
Your answer
School
Your answer
Grade(this year)
Gender
Student Cell Phone
Your answer
Parent/Guardian Name(s)
Your answer
Home Mailing Address
Your answer
Home Phone
Your answer
Parent/Guardian Work Phone
Your answer
Did you participate in any Career & Technical Education courses this year?
I/We (Parent/Guardian of Student) give consent for our child to participate in the 2017 Spring Crossing Our Bridges Health Academy. We understand that the academy will take place April 17-30, 2017. I/We understand that the above named child will abide by the rules and regulations as established by the school, the CSC, and the chaperones; should the above child not follow the rules and regulations, the school is not liable for the child’s activities. We understand we will be responsible for the cost of transportation home if this should be necessary.I/We consent to emergency medical treatment, hospitalization or other medical treatment as may be necessary for the welfare of the above named child, by a physician, qualified nurse, and/or hospital, in the event of injury or illness during all periods of time in which the student is away from his/her legal residence, as a member of this spring academy, and hereby waive on behalf of myself and the above named child any liability of the YKSD 2016 Spring Crossing Our Bridges Health Academy, any of its agents or employees, arising out of such medical treatment.I/We understand the local Board of Education or ASAA does not carry field trips, sports or activity insurance and will not assume responsibility for injuries sustained in this school activity or field trip. I/We also understand that accident insurance coverage is my responsibility.
Insurance Coverage:
To the fullest extent permitted by law, I/we (parent/guardian) agrees to defend, indemnify and hold harmless the Yukon-Koyukuk School District, its elected and appointed officials, employees, and volunteers against any and all liabilities, claims, demands, lawsuits, or losses, including costs and attorney fees incurred in defense thereof, arising out of or in any way connected or associated with this activity.
The electronic signature below and its related fields are treated by Yukon Koyukuk School District like a handwritten signature on a paper form.
Required
Date signed
MM
/
DD
/
YYYY
Personal Narrative ‘Tell Us about Yourself’ In 100 words or less, tell why you are interested in Health Care or an associated career and why you are interested in attending this academy.
Your answer
Teacher,Counselor or Principal Recommendation
(This form is to be completed by the Counselor, Teacher or Principal of the student’s current school)

Recommendation Instructions: This student is applying to participate in the Yukon-Koyukuk School District Spring Health Academy. Only twelve students will be selected to participate. This academy will provide students with an opportunity to explore career pathways, specifically in the area of healthcare.

In the space provided, please check the appropriate spaces and in the lined area write explanations to support the areas you have checked. Please give your best recommendation of the student using the following criteria:

Name and Title
Your answer
Leadership Ability
Ability to work with others
Work habits and study skills
Respect for those in authority
Behavior and attitude
This is student have accommodations or modifications described in an IEP or 504 plan?
Do you recommend the student for selection to the Spring Academy
Please add any additional comments:
Your answer
The electronic signature below and its related fields are treated by Yukon Koyukuk School District like a handwritten signature on a paper form.
Required
Date signed
MM
/
DD
/
YYYY
Student/Parent Contract
Program Rules and Regulations:

1. I understand that there will be no overnight visiting with friends while participating in the 2017 Crossing Our Bridges Health Academy.
2. I will follow the rules and regulations of my school.
3. I will keep regular attendance at the Academy classes and activities.
4. I will follow curfew regulations for the program.
5. I will not possess or use any drugs, alcohol, tobacco, or weapons while participating in the 2017 Crossing Our Bridges Health Academy program, and violation of this may result in my being sent home immediately at my parent/guardian’s expense.
6. I understand that violation of any state, federal, or municipal laws; such as stealing, shoplifting, etc., will result in my immediate removal from the Academy program at my parent/guardian’s expense.
7. I will show respect, honesty, courtesy, and cooperation toward my fellow students, and all Academy staff.
8. I understand that I will not be allowed to drive a motorized vehicle while participating in the Academy.
9. I will practice good health and hygiene habits, including limiting sugary snacks.
10. I will use appropriate language at all times.

I CERTIFY THAT ALL OF THE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND THAT I HAVE READ AND UNDERSTAND THE ABOVE STATED RULES AND REGULATIONS. I REALIZE THAT ANY VIOLATION OF THESE RULES MAY RESULT IN MY BEING DISMISSED FROM THE PROGRAM AT THE PARENT/GUARDIAN’S EXPENSE.

The electronic signature below and its related fields are treated by Yukon Koyukuk School District like a handwritten signature on a paper form.
Required
Date signed
MM
/
DD
/
YYYY
The above consent and release is hereby ratified and approved. The electronic signature below and its related fields are treated by Yukon Koyukuk School District like a handwritten signature on a paper form.
Required
Date signed
MM
/
DD
/
YYYY
Permission to Publish
For and on consideration of the opportunity and privilege of appearing in or participating in one or more video recordings, sound tracks, films, photographs, written articles or recordings, I hereby consent to the use and editing thereof and release Yukon-Koyukuk School District and their employees and assignee s from any and all claims resulting from such use, sale, editing, and release to the newspapers, and/or television channels or newsletters.
Parent or legal guardian signature is required if the participant is under 18 years of age.
The electronic signature below and its related fields are treated by Yukon Koyukuk School District like a handwritten signature on a paper form.
Required
Date signed
MM
/
DD
/
YYYY
The above consent and release is hereby ratified and approved. The electronic signature below and its related fields are treated by Yukon Koyukuk School District like a handwritten signature on a paper form.
Required
Date signed
MM
/
DD
/
YYYY
Request for Administration of Medication
If this form is properly completed and returned to the Spring CTE Academy Project Coordinator, the Yukon-Koyukuk School District may assist parents with their child’s physician prescribed medication for the child. The medication will only be given if it is delivered to the Spring CTE Academy Head Chaperone (in Galena) in the original bottle marked with the student’s name, dosage, time of administration, physician, pharmacy, and date of purchase
List any activities that should be restricted:
Your answer
Listen allergies the camper has:
Your answer
List any medications the camper must bring, with instructions and dosage instructions:
Your answer
List medications to which the camper is allergic:
Your answer
Give name and number of a friend or relative who may be contacted in case you're not available:
Your answer
Get date of last tetanus immunization(must be within 10 years)
MM
/
DD
/
YYYY
Do you give permission for over-the-counter medicines to be administered:
Health Statement
To the best of my knowledge, this student is in good health and is able to participate in all academic activities, within limitations as listed
Statement of parents/guardian
As parent/guardian (circle one) of the above named student, I do hereby request the school district to give medication to the above named student. I understand that the school district is not legally obligated to administer medication to the student, and in the absence of the school nurse, other school personnel will administer the medication. I agree not to institute suit against the school district for administration of non-administration of the medication, to defend and hold the school district harmless from any liability resulting from the administration or non-administration of the medication, and to defend and indemnify the school district an its employees from any liability arising out of this agreement. I will notify the CTE Project Coordinator if the medication is changed.
The electronic signature below and its related fields are treated by Yukon Koyukuk School District like a handwritten signature on a paper form.
Required
Date signed
MM
/
DD
/
YYYY
The electronic signature below and its related fields are treated by Yukon Koyukuk School District like a handwritten signature on a paper form.
Required
Date signed
MM
/
DD
/
YYYY
What to Bring to the Spring Health Academy
Clothing
o Changes of clothes for 11 days of academy (including underclothes)
o Change of socks for each day
o Winter gear (coat, hat, gloves, boots, etc.)
o Tennis shoes
o Swim Suit Grooming Items
o Toothbrush, toothpaste, dental floss
o Soap (in a zip lock baggie)
o Shampoo
o 1 bath towel & washcloth
o Comb or Brush

Miscellaneous Items
o Medicines in original container
o Book to read
o Sense of Humor
o Water bottle
o Small amount of money for store
o Computer (if have laptop)
o Headphones Do Not Bring These Items
o Valuables of any kind
o Weapons of any kind
o Drugs, Alcohol or Tobacco
o Radios/CD players
o Electronic games

Grooming Items
o Toothbrush, toothpaste, dental floss
o Soap (in a zip lock baggie)
o Shampoo
o 1 bath towel & washcloth
o Comb or Brush

Do Not Bring These Items
o Valuables of any kind
o Weapons of any kind
o Drugs, Alcohol or Tobacco
o Radios/CD players
o Electronic games

Submit
Never submit passwords through Google Forms.
This form was created inside of Yukon-Koyukuk School District. Report Abuse - Terms of Service - Additional Terms