city summer internship for girls · certi"cate of immunization (this can be from your...

City Summer Internship for Girls

Anpaidinternshipforgirlswhereyoulearntoearn.

Introducing Boston’s booming economy and amazing career opportunities for women.

Monday, July 9 – Fr iday, August 10, 2018

Location: Benjamin Franklin Institute of Technology 41 Berkeley Street, South End, MA 02116 Easily accessible by MBTA

2018 Work Hours: Monday-Tuesday-Friday 9 –1 pm Wednesday-Thursday 9 – 3 pm Must attend ALL days

To Apply: Applications available at [email protected] Call: 617-221-3912

Limited openings for girls who are Boston residents and will enter Grade 9 in September.

Preference given to Boston Public School students.

• Visit a new workplace each week with your team of interns to meet interesting professionals and do hands-on activities to build your skills and workplace knowledge.

• Learn more about what careers are available to women, what happens in the workplace and how one becomes a professional in a particular field.

• Explore the worlds of banking, urban planning, biotech, architecture or cyber security. Interns practice professional work skills and habits to prepare for a great paying job and future career in some of Boston’s most exciting workplaces.

• Get to know Boston’s amazing resources with visits to downtown neighborhoods, newest buildings and fun local landmarks.

Applicants earn $75/week. Interns are required to attend every day, arrive on time and complete weekly work assignments.

Apprentice Learning http://apprenticelearning.org/about-the-program/city-summer-internship/

LearningculinaryskillsatMentonRestaurant

City Summer Internship Mandatory Orientation for

Parent/Guardians

Wednesday, June 27 6:00 – 7:00 pm

Location: Mission Hill School 20 Child Street Jamaica Plain 02130

Enter the building on the Carolina Street side of

the building. Come to the second floor.

Please RSVP to Meaghan 617-888-1944 or [email protected]

STUDENT NAME ______________________________________ TODAY’S DATE ____________

APPLICATION FOR SUMMER 2018

APPRENTICE LEARNINGSubmit completed application to your school principal or email to [email protected] mail to P.O. Box 3000-68 Jamaica Plain, MA 02130

PLEASE PRINT CLEARLY

STUDENT INFORMATIONLAST NAME FIRST NAME DATE OF BIRTH

MALE FEMALE

STREET ADDRESS

CITY STATE ZIP

CURRENT GRADE LEVEL SCHOOL

RACE (Check all that apply)

PARENT/GUARDIAN INFORMATION

PARE

NT/

GUA

RDIA

N #

1 LAST NAME FIRST NAME PREFERRED PHONE HOME CELL WORK

STREET ADDRESS (ONLY IF DIFFERENT FROM STUDENT ADDRESS ABOVE) OTHER PHONE HOME CELL WORK

CITY STATE ZIP E-MAIL

PARE

NT/

GUA

RDIA

N #

2 LAST NAME FIRST NAME PREFERRED PHONE HOME CELL WORK



IN ADDITION TO THE PARENT/GUARDIAN 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 FIRST NAME PREFERRED PHONE HOME CELL WORK



EMERGENCY CONTACT: THE ABOVE WOULD BE AVAILABLE TO PICK UP YOUR CHILD DURING PROGRAM HOURS.

LAST NAME FIRST NAME PREFERRED PHONE HOME CELL WORK



EMERGENCY CONTACT: THE ABOVE WOULD BE AVAILABLE TO PICK UP YOUR CHILD DURING PROGRAM HOURS.

PLEASE

REQUIRED 1

CELL PHONE

ASIAN BLACK HISPANIC WHITE OTHER:___________________________

OTHER:___________

STUDENT ID #


APPRENTICE LEARNING

ENROLLMENT AGREEMENT

Registration/ConfirmationIn order for your child to be considered for enrollment, Apprentice Learning must receive:

Completed Program Application (See Pages 1 & 2.) Completed Enrollment Agreement A $30 non-refundable deposit must accompany application

Immunization History & Physical ExaminationMassachusetts law requires each child to have a current copy of Certificate of Immunization prior to the first day of the summer program. I understand that my child will not be permitted to participate in the program until the following additional paperwork has been completed and received by June 8, 2018:

Certificate of Immunization (This can be from your child’s school or doctor’s office. Required for all students.) Proof of Recent Physical Examination Medication, EpiPen & Inhaler Administration Form (See Page 5. Required only if bringing medication.)

Media and Liability ReleaseI 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 accept its terms.

DismissalI understand that Apprentice Learning reserves the right to dismiss any whose behavior interferes with the rights and safety of others. In such cases no refunds will be given.

Program & ActivitiesI 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.

PARENT/GUARDIAN SIGNATURE DATE

Submit completed application to your school principal or email to [email protected] mail to P.O. Box 3000-68 Jamaica Plain, MA 02130


REQUIRED 2



APPRENTICE LEARNINGSubmit completed application to your school principal or email to [email protected] mail to P.O. Box 3000-68 Jamaica Plain, MA 02130


HEALTH HISTORYPLEASE SELECT AND DESCRIBE ANY ALLERGIES.

PENICILLIN

SEASONAL: ____________________

FOOD: See below.

INSECT BITES: __________________

OTHER DRUGS: _________________

OTHER: _______________________

PLEASE EXPLAIN REACTION AND SEVERITY. PLEASE LIST MEDICATIONS FOR ALLERGIES:

IF MEDICATIONS ARE TO BE ADMINISTERED AT THE PROGRAM, THE MEDICATION ADMINISTRATION PORTION OF THIS APPLICATION (PAGE 5) MUST BE COMPLETED.

PLEASE CHECK THE MEDICATIONS AND OTHER PRODUCTS WHICH MAY BE ADMINISTERED TO YOUR CHILD, IF NEEDED.

ALL LISTED BELOW

TYLENOL

ADVIL

BENADRYL

SUDAFED

LORATADINE (Claritin)

COUGH DROPS

OTHER:

NONE LISTED BELOW

ANTACID

SUNSCREEN

CALAMINE

ANTI-ITCH CREAM

EXTERNAL ANTIBIOTIC CREAM

INSECT REPELLANT WITH DEET

MY CHILD WILL BE BRINGING MEDICATIONS (THIS INCLUDES OVER-THE-COUNTER MEDICINE) TO THE PROGRAM.


REQUIRED 3

IMMUNIZATION HISTORY & 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. I HAVE ATTACHED A CERTIFICATE OF IMMUNIZATION.

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.

I HAVE ATTACHED PROOF OF A RECENT PHYSICAL EXAMINATION.

COMPLETE THIS SECTION IF YOUR CHILD HAS ASTHMA

WILL YOUR CHILD WILL BE TAKING AN INHALER OR OTHER

ASTHMA MEDICATION TO THE PROGRAM? YES NO


PLEASE LIST ANY PHYSICAL, MENTAL OR PSYCHOLOGICAL CONDITIONS (SUCH AS ADD, ADHD, DIABETES, ETC.) REQUIRING MEDICATION, TREATMENT, OR RESTRICTIONS WHILE IN THE PROGRAM.

DOES YOUR CHILD TAKE ANY PRESCRIPTION OR OVER-THE-COUNTER MEDICATION AT HOME? YES NO

LIST ANY PAST MEDICAL TREATMENT OR RECENT INJURIES.

DESCRIBE ANY SPECIFIC ACTIVITIES IN WHICH YOUR CHILD CANNOT PARTICIPATE.

PLEASE LIST ANY DIETARY MODIFICATIONS OR RESTRICTIONS, INCLUDING FOOD ALLERGIES.



APPRENTICE LEARNINGHEALTH HISTORY (continued)PHYSICIAN/PEDIATRICIAN NAME/OFFICE PHONE

INSURANCE CARRIER INSURANCE POLICY HOLDER NAME MEMBER #

IS THERE ANYTHING YOU WOULD LIKE US TO KNOW ABOUT YOUR CHILD THAT WILL HELP HER HAVE A SUCCESSFUL EXPERIENCE?

AUTHORIZATIONS

ACCURACY OF INFORMATIONThis 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 WAIVERI hereby release and discharge and agree to indemnify and hold harmless Apprentice Learning and its 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.


REQUIRED 4




APPRENTICE LEARNING PLEASE PRINT CLEARLY

This form must be completed for any or all medications that will be brought to and administered at Apprentice Learning.

MEDICATION, INHALER AND EPIPEN® ADMINISTRATION

PRESCRIBED MEDICATIONS MUST:have a pharmacy label with the Rx number, name of the medication, and child’s nameinclude dosage and directions for use

NON-PRESCRIPTION MEDICATIONS MUST:be in their original containersbe clearly labeled with the child’s name include directions for use

All medications will be kept with the director. Please fill out the following information completely.

I hereby give permission for Apprentice Learning to administer the following medications to my child during his/her program attendance.


MEDICATIONNAME OF MEDICATION DAYS TAKEN

M T W T F AS NEEDED

WHY IS THIS MEDICATION TAKEN? TIMES TAKEN (PLEASE, BE SPECIFIC)

_______________ AM ______________ PM

OTHER:

ARE THERE ANY ADDITIONAL NOTES OR INSTRUCTIONS FOR THIS MEDICATION? DOSAGE

INHALERLOCATION OF INHALER AT APPRENTICE LEARNING

WITH CHILD WITH STAFF IN DESIGNATED STORAGE IN FIRST AID KIT

WHO MAY ADMINISTER INHALER?

CHILD QUALIFIED PERSONNEL (name):

EPIPEN®LOCATION OF EPIPEN® AT APPRENTICE LEARNING

WITH CHILD WITH STAFF IN DESIGNATED STORAGE IN FIRST AID KIT

WHO MAY ADMINISTER EPIPEN®?

CHILD QUALIFIED PERSONNEL (name):

REQUIRED 5

Student Medical Form Student’s School or Organization ________________________________ Program Date(s) ______________________________________________

Student Program Applicant Information To Parents: Thank you for completing this form on behalf of your son or daughter. Project Adventure, Inc. is a non-profit educational organization. Our programs use a wide variety of games, team-building activities, and low and high challenge course activities. At times, our programs also include outdoor activities such as orienteering and camping. (Since this is a general description only, please refer to accompanying information or school personnel to find out more about the specific activities planned for your son or daughter’s program.) Although some of these activities can be physically demanding, they are designed to be within the capability of any student who is in reasonably good health. Safety is a very high priority for all of our programs. Please help us by providing the information requested below. If your child has any current or past medical conditions that could affect their participation, please let us know. If you have additional questions about this program please contact the appropriate school personnel or a representative of Project Adventure. Thank you.

General Information (please print) Student’s Name _______________________________________________

Student’s Date of Birth _________________ Sex: □ M □ F

Student’s Home Address_________________________________________

_____________________________________________________________

Is this student covered by medical insurance? □ Yes □ No

If yes, please list the insurance provider

_____________________________________________________________

Parent(s)/Guardian(s):

Please let us know the best way to contact you if needed. (please print)

Name _______________________________________________________

Primary phone number __________________________________________

Secondary phone number ________________________________________

If you are not available in an emergency, please indicate an additional

person to be notified.

Name _______________________________________________________

Primary phone number __________________________________________

Secondary phone number________________________________________

Relationship to student__________________________________________

(Please continue on other side)

Medical Questions 1. Does your child have any current or past medical conditions that could affect their ability to participate in Project Adventure activities?

□ Yes □ No

If yes, please identify and explain: 2. Does your child have any of the following conditions? If taking

medications for any of these conditions please list in question #3.

□ Chronic or recurring illness

□ Recent injury

□ Diabetes

□ Allergies (medication, food, bee stings, etc.)

□ Asthma

□ Recent surgery

3. Is your child currently taking any medications? □Yes □No

If yes, please state what he or she is taking and the condition being treated.

Photo/Media Release Project Adventure programs are often recorded in photos, videos and other digital media and this material is sometimes used in Project Adventure publications (e.g. brochures, promotional materials, etc.). Project Adventure reserves the exclusive right to use any such material obtained during Project Adventure programs for its own use. Any program participant or parent of a program participant may choose not to be photographed or otherwise recorded simply by informing an authorized Project Adventure representative.

Release of Liability –Acknowledgment of Risk I understand that this Project Adventure program will be conducted outdoors and that it is designed to be challenging as well as educational. I recognize and acknowledge that even though the program has been carefully designed and will be operated by well-trained staff, the risk of injury or disability cannot be totally eliminated. In the event of illness or injury, consent is hereby given to access and provide emergency medical care or hospitalization. I affirm that the information provided on this form is accurate and complete and I agree to hold Project Adventure harmless if full disclosure of a pre-existing medical condition has not been provided. I release Project Adventure, Inc., its staff members and Board of Directors, from all liability not directly related to the actions of Project Adventure staff members. __________________________________________ ___________ Signature (parent or guardian) Date

Questions or Concerns? Please call: 978-524-4500 Please visit our Web Site: www.pa.org 719 Cabot Street, Beverly, MA 01915

http://www.pa.org/

City-Wide Measurement Project Consent Form – Please sign and return

Dear Parent/Guardian, This program is taking part in a city-wide program evaluation project (the “Measurement Project”) for all or part of the May 2018-July 2019 year. This Measurement Project, managed by Boston After School & Beyond, Inc. (“BASB”), seeks to understand the quality of out-of-school and expanded learning time programming in Greater Boston and how programs support student skill development and learning. Several research organizations will help with the Measurement Project: National Institute on Out-of-School Time (“NIOST”), The PEAR Institute (“PEAR”), the RAND Corporation, and ExpandED Schools (collectively, “Research Organizations”). By completing, signing, and returning this Consent Form, you acknowledge and agree to the following: 1. BASB, Research Organizations, and Boston Public Schools (“BPS”) will have access to the following demographic and academic

information about your child (obtained from this Program and/or BPS): student program attendance, school attended, race, gender, grade, age/date of birth, English language learner (ELL) status, home zip code, school-year attendance (days present, days tardy, rate), discipline records (total suspension incidents, days suspended, expulsions), test scores, State Assigned Student Identifier (SASID) and Boston Public Schools ID. These data are confidential and will be used only for evaluation to improve out-of-school time programming.

2. Students in grades 4 - 12 may be asked to fill out a survey called NIOST Survey on Academic and Youth Outcomes (“SAYO Y”). The SAYO Y is a brief survey taken at the end of programming which asks students about their program experiences and future plans. Participation in the survey is voluntary and students may stop at any time without penalty. Individual responses will not be shared with the Program. Should you have any questions about this survey, use of these data, or your child’s participation, contact Dr. Georgia Hall at (781) 283-2530 or [email protected], or Nancy L. Marshall at [email protected].

3. Students in grades 5 - 12 may be asked to fill out a survey called the Holistic Student Assessment (“HSA") and/or the Common Instrument survey (“CI”), developed by PEAR. The HSA is a tool that can deepen understanding of students’ social and emotional strengths and needs. Students complete a brief survey about themselves, at least once and as many as two times. The Program will use the HSA results to cultivate the strengths, abilities, and academic success of each student. The CI is a brief survey completed once which assesses student interest in science, technology, engineering, and math. CI results will be used to improve program content and delivery. Participation in the survey(s) is voluntary and students may stop at any time without penalty. BASB, BPS, and Research Organizations will have access to HSA and CI data and results. PEAR reserves the right to use all HSA and CI data for both research and educational purposes. Should you have any questions regarding HSA or CI, contact Jane Aibel at 617-484-0466 extension 204 or [email protected].

4. BASB and/or their partners/agents may videotape or take photos of your child’s participation in the program using video and/or digital photography. These images may be taken before, during, or after programming. These images may be used for the purpose of sharing your child’s participation and associated perspectives to a public audience. Images may be published, posted, or played through a variety of communication channels, including but not limited to print, television, and/or online.

Confidentiality of Data Collected Your child’s participation in the Measurement Project data collection helps us to better understand out-of-school time programming in Greater Boston. All data collected that may identify your child will be kept confidential. In public reporting of research findings, only group data and/or de-identified data will be reported. At no time will a public report identify an individual student in any way. The only exception to confidentiality will be in the case of any information disclosed that indicates a child is in any danger.

Please complete, sign, and return. By signing this form below, I give permission for my child to participate in the Measurement Project, and I acknowledge that I have read, understand, and agree to all aspects of the Measurement Project as described in this form. The program will provide services to my child regardless of whether I sign this form.

Program in which your child is enrolling: __________________________________________________________________________

Child’s Full Name (First, Middle, Last): ____________________________________________________________________________

Child’s Date of Birth: ____________________________________ Child’s School-Assigned ID #: ___________________________

Child’s Gender: _____________________________________ Child’s Grade (School year 2018-2019): _____________________

Child’s School: _______________________________________________________________________________________________

Parent/Guardian Name: ______________________________________________ Relationship to Child: _____________________

**PARENT/GUARDIAN SIGNATURE**: _________________________________________________ Date: ___________________

city summer internship for girls · certi"cate of immunization (this can be from your...

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