Youth Volunteer Program Submission Please enable JavaScript in your browser to complete this form. - Step 1 of 2Volunteer's Name *FirstLastAge *Sex *MaleFemaleNon-binaryPrefer not to respondDate of Birth *Schooling *Elementary Education (Grades K-6)Secondary Education (Grades 7-12)Years of French *Mother's Name *FirstLastStreet Address *City/State *ZIP Code *Phone Number *Email *Employer & Occupation *Employer Street Address *City/State *ZIP Code *Work Phone Number *Work Email *Can we contact you at work? *YesNoFather's Name *FirstLastStreet Address *City/State *ZIP Code *Phone Number *Email *Employer & Occupation *Employer Street Address *City/State *ZIP Code *Work Phone Number *Work Email *Can we contact you at work? *YesNoEmergency Contact #1 *FirstLastNote: Contact cannot be parent listed aboveEmergency Street Address *City/State *ZIP Code *Phone Number *Relationship *Emergency Contact #2 *FirstLastNote: Contact cannot be parent listed aboveEmergency Street Address *City/State *ZIP Code *Phone Number *Relationship *Student's Physician *Physician Street Address *City/State *ZIP Code *Phone Number *Known Allergies/IllnessesFood RestrictionsMedications Regularly TakenOther Significant Medical InformationNextPermission Statements1. I give permission to the staff of Mes Amis to take whatever emergency measures (including medical or surgical care) are judged necessary for the care and protection of my child while under the supervision of the school. (Yes/No) *2. *I understand that in some emergency situations Mes Amis will need to contact the Emergency Medical Service (911) before the parent, child’s physician, or other adult who it acting on the parent’s behalf. In the event of a non-life threatening medical emergency, my child should be transported to _________________ Hospital. If it is a life threatening medical emergency, I understand that my child will be transported to Methodist Hospital which is closest to Mes Amis. My child will be transported at my expense.Hospital Name *3. *In consideration of your acceptance of my child as a student at Mes Amis French School, or St. David’s Episcopal Church I hereby waive, release, indemnify, and agree to hold harmless Mes Amis French School, LLC its employees, and agents, from any claim arising out of any and all injuries suffered by my child incidental to or connected with any activity sponsored by Mes Amis French School, LLC.4. I give Mes Amis permission to use photographs or video of my child for publication in school materials at the discretion of Mes Amis French School. (Yes/No) *5. I give my permission for a Mes Amis director or qualified teacher to help my child to follow up including the administration of medication under the instruction of Poison Control. (Yes/No) *6. I give my permission for a staff member of Mes Amis to apply sunscreen lotion according to the Manufacturer’s directions on my child. I understand that this is not an ordinary procedure and, if necessary, should be applied before coming to school. (Yes/No) *7. I give my permission for a staff member of Mes Amis to apply insect repellant lotion according to the manufacturer’s directions on my child. I understand that this is not an ordinary procedure and, if necessary, should be applied before coming to school. (Yes/No) *8. I give my child permission in the field trips included in the activities for which they are registered. (Yes/No) *9. I give Mes Amis French School permission to be in the school’s directory. (The information in this directory is not for sales opportunities or for any other use than for sharing information that would benefit the students of Mes Amis. It will be shared with families who registered with the school, and is not to be shared with other entities. The directory will be sent via email periodically, as updates are made). (Yes/No) *Signature *Submit
