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Metropolitan Preparatory AcademyAnd High School Unplugged
2013
Application Form and Health, Contact and Permission Forms
SUMMER IN GUATEMALAAPPLICATION FORM
2013
The Metropolitan Preparatory Academy – High School Unplugged collaboration is a transformational learning experience that will change your life! Please work with your parents and your school administration to fill out this application form, and return it to us by April 28, 2013 to [email protected].
STUDENT AND FAMILY CONTACT INFORMATION
Today’s Date:______________________
Full name of student as it appears on passport:
____________________________________________
Nickname or common name: ________________
Sex: ____ Date of Birth: ___/__/____Nationality: _________________D/M/Y
Country of Residence: ____________________________
Country of Passport and Number: ______________________________
Date of Issue: __/___/______Expiry Date: __/__/__________D M Y Y D M YY
Place issued: ____________________________
Complete Address of Primary Residence: ________________________Number and Street
City Province Postal Code
Telephone: Home ____________________ Cell_________________
Email Address: _____________________________________________
Legal Guardian/Parent Number One:
First Name Last Name
Relation to Student: _____________________________
Complete Street Address:
Number and Street
City Province Postal Code
Home Telephone: ( ) __________________________Work Telephone: ( ) __________________________Mobile Telephone: ( ) __________________________
Email Address: _________________________________________
Legal Guardian/Parent Number Two:
First Name Last Name
Relation to Student: ___________________________________
Complete Street Address:
Number and Street
City Province Postal Code
Home Telephone: _________________________Work Telephone: _________________________MobileTelephone: _________________________
Email Address: ___________________________
Responsibility for Payment: Please indicate with a check mark√Guardian One: ___Guardian Two: ___ Other: ___________________________If other, please provide all contact information for this party:
Name________________________Address________________________
City______________________Province______________ Postal Code______ Telephone__________________Email Address:__________________________________
Relation to Student: ________________________________________
STUDENT ACADEMIC INFORMATION
School Name: __________________________________________________
Complete School Mailing Address: ____________________________________________________ Number and Street
Province: ________________ Postal Code___________________
School Telephone: ________________________
School Website:___________________________
Name of Head of School or Guidance Counselor:
______________________________________________
Telephone, Head of School or Guidance Counselor:
Email of Head of School or Guidance Counselor:
Student’s Current Grade: ______________Grade Student Will Enter Next Academic Year: _______Current Grade Point Average: ________
Have you have been subject to disciplinary action?This would include suspension, expulsion, academic probation, arrest, etc., in or out of school from the beginning of grade nine and forward (yes/no):
If yes, please provide details:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
In 100 words or fewer, please indicate why you want to travel and study in Guatemala this summer and what you hope to gain from the experience:
In 100 words or fewer, please add any additional information you think will be
relevant. For example, have you traveled or studied abroad before? Is this transformational learning experience applicable to your plans for higher education?
Do you have any special connection to Guatemala or Latin America?
Confirmation of Undertaking by Student:Student
I certify that the above information is correct; that I am in good physical, emotional and mental condition to participate in a trip to Guatemala, and that I am willing to abide by all program rules and standards of behavior.
Student Name: __________________________ ____________________ _____/_______/_____ Student Name (Printed) Signature D M YY
Head of School or Guidance Counselor*Feel free to write or contact us with questions or comments.
I certify that the above information is correct and that in my judgment this student applicant is academically, socially, physically, emotionally and mentally qualified to participate in the Summer in Guatemala Program.
Name:_______________________ Title:__________________________
Institution: __________________________________________________
Signature:_________________ Date___/___/___/ D M YY
Parents/Guardians
*All adults who must give consent for a student to travel abroad are required to sign.We certify that the above information is thorough and correct, and that pending the completion of subsequent paperwork we will give permission for the student applicant to attend the Summer in Guatemala program. We agree to fulfill by deadline all requirements for health and
safety measures (vaccinations, purchase of insurance, etc.), and to be available by telephone and email during the duration of the program. We certify that the student applicant is in good physical, emotional and
mental condition to participate in a trip to Guatemala. We understand that if the student applicant fails to abide by all program rules and standards of conduct, he or she will be sent back to his/her town of origin at my/our expense.
Parent/Guardian: ______________________ _________________
Name Printed Signature
Date______________
Please fill out this form and its various components fully and return it to us by April 30, 2013 at [email protected] , along with the following required attached documents:
An electronic scan (PDF or JPG) of your child/dependent’s passport. Proof of travel and health insurance (PDF or JPG scan). If you do
not have your own International Coverage we can recommend exceptional third party providers.
A recent digital, close-up, “head and shoulders” photograph of child/dependent.
EMERGENCY CONTACT INFORMATION
Alternative Emergency Contact Number One (In Case Parent/Guardian Unreachable)Name:
Relation:
Complete Address:
Street City Postal Code
Cellular Telephone: ___________________________
Email Address: _______________________________
Alternative Emergency Contact Number Two (In Case Parent/Guardian Unreachable)Name: ________________________________
Relation: _______________ Complete Address:_____________________
City__________ Province___________ Postal Code ________________Home Telephone: _______________________________
Work Telephone: _______________________________
Cellular Telephone: ______________________________
Email Address: __________________________________
STUDENT DIET INFORMATIONPlease indicate any of the following that apply:
KosherVegetarianVeganLactose IntolerantOther (please provide details below)
Details/Comments:
STUDENT ALLERGY INFORMATIONPlease indicate any of the following allergies that apply and provide details:
Hay FeverInsect Stings (please provide details below)Drugs (please provide details below)Food (please provide details below)Other (please provide details below)
Details/Comments:
STUDENT HEALTH INFORMATIONPlease indicate any of the following that you have experienced and provide details:
Asthma (please provide details below)Chicken Pox (please provide details below)Heart Disease/Defect (please provide details below)Frequent Fevers (please provide details below)Frequent Nosebleeds (please provide details below)High Blood Pressure (please provide details below)Frequent Ear Infections (please provide details below)Gastric Disorders (please provide details below)Eating Disorders (please provide details below)Clinical Depression (please provide details below)
Details/Comments:
HEALTH QUESTIONNAIRE
1. Have your child/dependent ever had any serious illnesses or accidents? If so, please provide details:
2. Is your child/dependent on any medications? If so, please provide all details and dosages. Please note that your child/dependent must bring all medications with him or her to Guatemala.
3. My child/dependent’s blood type is:
4. Please indicate any additional comments or concerns.
HEALTH CONSULTATION CERTIFICATIONIt is the responsibility of each family to consult a travel health specialist in reference to a trip to lowland and highland Guatemala, and to acquire any and all recommended vaccinations and/or medications in a timely manner before the date of travel. In this section, you both you and the health provider certify that you have done so. The stamp and signature of a licensed health professional is required. Please remember to send proof of travel and health insurance along with this application.
I/we have consulted a travel health specialist in reference to all issues related to a trip to Guatemala, including but not limited to immunization, malaria prophylaxis, and management of pre-existing conditions. I/we affirm that the health history provided is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed activities unless specifically noted. In the event a parent/guardian cannot be reached in an emergency, I/we hereby give permission to the physician selected by High School Unplugged to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for _____________________________________. Every effort will be made by High School Unplugged to immediately contact a parent/guardian in the event of an emergency. Unless otherwise specified, High School Unplugged may administer over-the-counter drugs to if needed.
(All responsible adults are asked to sign.)
Parent/Guardian Signature and Date: __________________________ ___________
Parent/Guardian Signature and Date: __________________________ ____________HEALTH PROFESSIONAL SIGNATURE AND STAMPI have been consulted on behalf of ________________________________________ (student) in reference to a 28-day trip to Guatemala and have provided the family with the health information needed to for them to make an informed decision regarding the student’s participation. None of my professional advice counter-indicates participating in a trip to Guatemala.
Name, Title, Institutional Affiliation,
Address: Number and Street ____________________ City _____________ Province ______ Postal Code ________________________
Signature, Stamp and Date: Date:
PERMISSION SLIP AND RELEASE FORM
The following form is a permission slip/waiver to participate in the High School Unplugged Transformational Learning Experience in Guatemala that constitutes a
direct agreement between individual parents and High School Unplugged. Its intent is to avoid misunderstandings, make sure you are informed, and help ensure the safety
and security of your child or dependent while in Guatemala.
RISK AND RELEASE FORM: GUATEMALAN VOYAGE, SUMMER 2013
Note: This is a release of your legal rights. Read and understand this document before you sign. If the student has more than one legal guardian, both are required to sign.
Parent/Guardian’s Name:_________________________________________________________________________ Last First Middle
Parent/Guardian’s Name:________________________________________________________________________ Last First Middle
Traveling Student’s Name:_________________________________________________________________________ Last First Middle
By signing this document, I agree to the following:
1. Acceptance of Program Destinations. I have examined the destinations in the
High School Unplugged transformational learning excursion to Guatemala in July
2013 and agree for my child/dependent to participate in the trip.
2. Risk of Studying Abroad in Guatemala: I understand that participation in the
High School Unplugged transformational learning excursion to Guatemala in July
2013 (hereinafter referred to as “the Program”) involves risks inherent to traveling
in the developing world. These include but are not limited to: risks involved in
traveling to and within, and returning from, Guatemala; political, legal, social, and
economic conditions in Guatemala; different standards of design, safety, and
maintenance of buildings, public places, and conveyances in Guatemala; and local
medical and weather conditions. I have made my own investigation and accept
these risks. I understand that High School Unplugged is not responsible for matters
that are beyond its control. I hereby release High School Unplugged and its legal
representative(s) from any injury, loss, damage, accident, delay, or expense arising
out of such matters.
3. Institutional Arrangements: 1) I understand that High School Unplugged does
not represent or act as an agent for, and cannot control the acts or omissions of my
child/dependent’s school or of the hotels or other providers of goods or services
involved in the Program. 2) I understand that although academic documentation
for the trip will be provided, and in many cases may be pre-arranged with my
child’s school, the ultimate arrangement of academic credit for participation in the
program is dependent upon my child or dependent’s school is my responsibility,
and that no guarantee of academic credit is stated or implied. 3) I release from all
legal responsibility any institutions that cooperate with High School Unplugged in
this Program.
This year’s accreditation will be through Metropolitan Preparatory
Academy. This is an accredited Secondary School and is inspected by the
Ontario Ministry of Education. The Ministry in giving accreditation to
Metro Prep does so knowing that each course credited will be so
accredited after the student has successfully fulfilled the 110 hours
required and completed all assignments and written a final exam or
culminating project. High School Unplugged guarantees that each
student will have 110 hours of class time.
4. Health and Safety:
A. I am aware of all applicable personal medical needs of my child or dependent. I
have insurance and have arranged to meet any and all needs for payment of
medical costs during the period of participation in the Program.
B. I certify that my child/dependent is in fit condition physically, socially,
emotionally and mentally to participate in the Program.
C. I am aware that certain portions of the Program are conducted at considerable
distance from good hospitals. I have conducted research on travel medicine
and understand and assume the risk of traveling to the tropics.
D. By this instrument, High School Unplugged has made me aware that emergency
medical helicopter transport to the Guatemala City airport is offered by an
independent company called Helicopteros de Guatemala
(www.helicopterosdeguatemala.com) when helicopters are available to fly. I
authorize High School Unplugged to contract and pay for this service if it deems
necessary, and guarantee payment and release High School Unplugged from
liability in accordance with the terms below.
E. I have fully communicated to High School Unplugged any extenuating medical
circumstances (for example, asthma, allergies, or other conditions), and have
provided High School Unplugged with any materials or medications needed in
the case of a related emergency in full knowledge that in Guatemala such
materials or medications may not be on hand or nearby.
F. I am aware that the group will not be accompanied by a medical professional.
G. If my child requires medical treatment or hospital care in Guatemala or another
country during the Program, High School Unplugged is not responsible for the
cost or quality of such treatment or care, or injuries arising from or related to
such care.
H. High School Unplugged may take any actions it considers to be warranted under
the circumstances regarding my child or dependent’s health and safety. I agree
to pay all expenses related thereto and release High School Unplugged from any
liability for any actions or inaction.
5. Standards of Conduct:
A. I agree that my child or dependent must comply with the rules, standards, and
instructions established by group leaders, and must obey Guatemalan law.
Drinking and drug use are prohibited. Leaving the group is prohibited. I
understand that while the group is accompanied by adults, the students will not
be under direct, physical supervision at every moment, and that it is my child or
dependent’s responsibility to comply with group leaders’ instructions. I waive
and release all claims against High School Unplugged or its representatives that
may arise from my child or dependent’s failure to obey these rules and
instructions and remain under the supervision of group leaders, or to comply
with such rules, standards, laws and instructions.
B. I agree that High School Unplugged has a right to enforce the standards or
conduct described above, in its sole judgment, and that it will impose sanctions,
up to and including expulsion from the Program, for violating these standards or
for any behavior detrimental to or incompatible with the interest, harmony, and
welfare of High School Unplugged, the Program, other participants, or third
parties. If my child or dependent is expelled, I consent to his or her being sent
home at my own expense.
6. Assumption of Risk and Release of Claims: Knowing the risks described
above, I agree to assume all the risks and responsibilities surrounding participation
in the Program. To the maximum extent permitted by law, I release and indemnify
High School Unplugged, and its legal representative(s), officers, employees, and
agents, from and against any present or future claim, loss, or liability for injury to
person or property which my child or dependent may suffer or be liable for to for
any other person, during my child or dependent’s participation in the program
(including periods in transit to or from Guatemala).
7. Arbitration Clause: I understand and accept that any dispute that cannot be
amicably and mutually resolved arising from or related to the terms and scope of
this document shall be resolved under the laws of the Province of Ontario,
subjecting the resolution of disputes to arbitration.
8. As the parent or legal guardian for the above named student, I have read the
foregoing Assumption of Risk and Release and will be legally responsible for the
obligations and acts of the student as described in this Assumption of Risk and Release
and agree for myself and for the student to be bound by its terms.
Parent/Legal Guardians
1. Name: _________________________________________________________
Last First Middle
Signature: _________________________________________________________
Date: ___ / ___ / ___
City: __________________ Country: ______________________
2. Name: _________________________________________________________
Last First Middle
Signature: _________________________________________________________
Date: ___ / ___ / ___
City: __________________ Country: ______________________
