High School Internship Application Summer 2008
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Name: ________________________________________________________________________
Date of birth: _____________________School: _________________________ Grade _______
Address of residence:_____________________________________________________________
Street City State Zip
Parent/Guardians’ names: _________________________________________________________
Parent(s) Contact Phone Numbers: (Home)____________________(Work)__________________
(Emergency)____________________________(Other)__________________________________
E-mail address:__________________________________________________________________
Related work and/or volunteer experience (ie: babysitting, youth group activities, Flagship activities)______________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
What do you hope to gain this summer while volunteering with Flagship? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list 2 references
Name Address Phone # Relationship to you
___________________________________________________________________________
___________________________________________________________________________
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The following information will help us provide you with needed care:
Medical insurance provider ______________________ Policy number ____________________
Parents
In the event it becomes necessary for the Flagship staff in charge to obtain emergency care for my child, neither he/she nor the Flagship Program assumes financial liability for expenses incurred because of an accident, injury, illness and/or unforeseen circumstances. I authorize Flagship employees and volunteers in charge of the students to obtain all necessary emergency care and authorize any licensed physician an/or medical personnel to render necessary emergency treatment to my child.
By signing below, I give permission for the following:
My child to ride in buses, vans, cars, and bikes hired, rented, or driven by Flagship staff or volunteers
My child’s name and/or picture to be used in films, videos, media releases, written information or brochures produced to promote the work of the Flagship Program.
I HAVE READ AND UNDERSTAND THIS FORM IN ITS ENTIRETY.
_____________________________ ___________________________
Parent/Guardian Signature Date