Summer STAND application - Dearborn Public Schools

DEARBORN PUBLIC SCHOOLS
SUMMER STAND PROGRAM
APPLICATION/PERMISSION TO PARTICIPATE & ACCIDENT WAIVER FORM
(PLEASE PRINT) Age on June 30, 2011 __________
Student’s Name: __________________________________________ Date of Birth: __________________
Street Address: ___________________________________________ Home Phone: ____________________
City: _________________________ State: _____ Zip: _________ School: _________________________
Mother/Guardian’s Name: ___________________________________ Home Phone : _________________
Email Address: ___________________________________________________ Cell Phone : ______________________
Place of Employment: ______________________________________________ Work Phone: _____________________
Father/Guardian’s Name: ____________________________________ Home Phone : _________________
Email Address: ___________________________________________________ Cell Phone : ______________________
Place of Employment: ______________________________________________ Work Phone: _____________________
Relative/Neighbor who will assume temporary care of your child if you cannot be reached.
Name:___________________________________________________________ Daytime Phone: __________________
Name:___________________________________________________________ Daytime Phone: __________________
List any and all physical/medical conditions which may affect participation in any SUMMER STAND Program physical
activity. Please explain:
____________________________________________________________________________________
____________________________________________________________________________________
List any learning differences, psychiatric issues or family issues your child is dealing with: ___________________________
____________________________________________________________________________________________________
List any medication student is taking: (If your child is taking medication for ADD or ADHD, please don’t take him/her off of
their medication for the summer.)
____________________________________________________________________________________
____________________________________________________________________________________
Family Doctor _____________________________ Phone # where doctor can always be reached _____________
Doctor’s Address ______________________________________________________________________________________
PARENT/LEGAL GUARDIAN
I, ____________________________________________________, give my permission for my child to participate in the
SUMMER STAND Program and release the Dearborn Public Schools SUMMER STAND Program from any and all
liabilities or responsibilities pertaining to accidents, injuries, or complications resulting from activities, or while transporting
participants to activities. Transportation may consist of bus, van, or car. Activities will include field trips within city limits
and extended field trips away from Dearborn Public Schools. A schedule will be provided.
I authorize the SUMMER STAND Program leadership to transport the above name participant to the nearest hospital in case
of injury or suspected injury while the participant is involved in a SUMMER STAND Program activity.
I authorize the hospital attending physician to administer necessary emergency professional medical care to the above named
participant upon his/her arrival at the hospital.
____________________________________________________________________________________________________
PARENT/GUARDIAN SIGNATURE DATE
NOTE: THIS FORM MUST BE COMPLETED, SIGNED, AND RETURNED BEFORE THE
NAMED PARTICIPANT CAN BE ASSIGNED TO THE PROGRAM.

DEARBORN PUBLIC SCHOOLS
SUMMER STAND PROGRAM
Medication Authorization Form
(Fill out only if student will be taking medication during program time.)
Medication administered during program hours by program personnel requires written orders from a physician. Medication
must be brought to the program site in a labeled pharmacist bottle each time a supply is sent.
Physician Authorization
___________________________________________________________ __________________
Student’s Name Age
________________________________________________ ______________________________
Medication Dosage
_________________________________________________ ______________________________
Method Time Frequency
________________________________________________ ______________________________
For period from (date) to
Reason for Medication: ___________________________________________________________________
____________________________________________________________________________________
Relevant Side Effects: _____________________________________________________________________
____________________________________________________________________________________
Special Instructions to SUMMER STAND staff: __________________________________________________
____________________________________________________________________________________
__________________________________________ ____________________________________
Physician’s Signature Physician’s Name (printed please)
__________________________________________________ ___________________________________________
Street Address City State Zip
__________________________________________________ ___________________________________________
Telephone Date
Parent Authorization
I request that the SUMMER STAND Program personnel give my child:
____________________________________________________________________________________________________
(The medication ordered above by his/her physician)
__________________________________________________________________ ____________________________
Parent/Guardian Signature Date
For medication to be administered at school, it must be supplied in original container, clearly labeled
with the student’s name, doctor’s name, dosage, name of medication, and specific instruction on the
time(s) for administering the medication.

Dearborn Public Schools accept a parent’s assertion that he or she needs language assistance without requiring additional corroboration.
For free help with understanding the content of this document, please call the Student Services office 827-3005 for translation/interpretation
assistance.
Arabic مقرلا ىلع بلاطلا تامدخ بتكمب لاصتلإا ىجري ةرامتسلإا هذه مهفلو ةّيناجملا ةمدخلا هذه ىلع لوصحلل.طرش
يأ نودب ةمجرتلا تامدخ ريفوت ىلع نروبريد سرادم دكؤت
. 728-5003
French Les écoles de Dearborn vous offrent le service de traduction sans aucune condition. Si vous souhaitez avoir le service gratuit pour
comprendre le contenu de ce document, prière d'appeler le bureau de Services aux Etudiants 827-3005.
Spanish Las escuelas de Dearborn aceptan la afirmación de un padre que él o ella necesita ayuda con el idioma sin necesidad de
corroboración adicional. Para obtener ayuda gratuita con la comprensión del contenido de este documento, por favor llame a la oficina de
Servicios de los Estudiantes 827-3005 para recibir asistencia de traducción / interpretación.
Italian Scuole Dearborn accettare l'affermazione di un genitore che lui o lei ha bisogno di assistenza lingua senza bisogno di ulteriori
conferme. Per aiuto con la comprensione del contenuto di questo documento, si prega di chiamare l'ufficio Student Services 827-3005 per la
traduzione / interpretazione di assistenza.
Albanian Shkolla DEARBORN pranojnë pohimin e të prindërve që ai ose ajo ka nevojë për ndihmë të gjuhës pa kërkuar vërtetim shtesë. Për
ndihmë lirë me kuptuar përmbajtjen e këtij dokumenti, ju lutemi telefononi zyrën e shërbimeve për studentë 827-3005 për përkthim /
interpretim ndihmë.
Romanian Scolile orasului Dearborn accepta orice declaratie parinteasca care atesta nevoia copilul de assistenta cu limba engleza fara nici
o dovada suplimentara. Daca aveti nevoie sa intelegeti acest document da-ti telefon la oficiul serviciilor scolare la numarul 827-3005 pentru
a primi asistenta cu translatia sau interpretarea lui.
Urdu وک داوم ےک زيواتسد
سا.ںيہ ےترک لوبق وک ےہ ترورض یک دادما نابز ريغب ےہ یتوہ ترورض یک نواعت یفاضا هو اي هو ہک ےہ یوعد اک نيدلاو ںيم ںولوکسا نروب رئيڈ
.
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ںيرک لاک وک رتفد ےک تامدخ یک ملع بلاط ےئل ےک حيرشت / ہمجرت ددم ینابرہم هارب ،ےئل ےک ددم ںيم تفم هتاس ےک ےنهجمس