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Schulenburg ISD
Agricultural Science & FFA
Student Handbook2012-2013
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Table of ContentsWelcome 3Officer Team 4Awards Program 5Scholarship Opportunities 6Competitive Team Activities 8Leadership Activities 9Ethics & Official Dress 10Ag Science Course Offerings 11FFA Fundraising Activities 12FFA Member Participation 13Hours Program 14FFA History, Dues and Jackets 15Useful Links 16Calendar of Activities 17Overnight Trips 19Parent Travel Permission Form 21Emergency Information Form 22
The Schulenburg ISD does not discriminate on the basis of race, color, national origin, religion, sex, age or disabilities in providing educational services, activities and programs, including Career and Technical Education programs, in accordance with Title VI of the Civil Rights Acts of 1964, as amended; Title IX of the Educational Amendments of 1972; Section 504 of the Rehabilitation Act of 1973; as amended, and the Title II of the Americans with Disabilities Act.
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August 8, 2012
Dear Students and Parents:
Welcome to the 2012-2013 school year and the Schulenburg FFA and
Schulenburg Agricultural Science Department. It is enlightening to see the new and
returning students in our program. This year’s program of activities is loaded with a
wide array of challenges and activities for your participation.
The Agricultural Science Program consists of three elements, Classroom
Instruction, Supervised Agricultural Experience and the FFA. This is a unique program
and we believe it will be a life-changing experience for you. There are many
opportunities for you to develop leadership skills as well as experience personal growth
throughout your participation.
We look forward to each of you attending the plethora of activities and meetings
available. It is a great way to make new friends and create camaraderie which will last a
lifetime. Remember, as with any endeavor you pursue, you only get out of this
organization what you put into it. We are here to offer guidance and support for each
of you. Please do not hesitate to contact one of us if we can be of any assistance.
Sincerely,
Amy Hartman Brad [email protected] [email protected]
Shaye [email protected]
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2012-2013 Schulenburg FFA Officer Team
President: Kate Lewis
Vice-President: Chelsea Kubenka
Secretary: Sami Hall
Treasurer: Tanner Guentert
Reporter: Sydney Little
Sentinel: Dakota Zapalac
Student Advisor: Dillan Drabek
Historian: Taylor Olsovsky
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Awards ProgramThe Schulenburg FFA Chapter has several award opportunities for members to
participate. Each spring, the Schulenburg FFA hosts an Awards Banquet to recognize the
achievements of FFA members. Members must complete an application and submit it
before the required deadline which will be announced in the spring semester.
Applications will be judged by an outside panel of Agricultural Science Teachers from
the District and Area Associations. The following awards will be awarded on the chapter
level:
1. STAR AWARDS Star Greenhand (First Year Member) Star Chapter Farmer Star Lone Star
2. PROFICIENCY AWARDS Members will be awarded certificates based upon their Supervised Agricultural
Experience Program
3. OUTSTANDING FFA MEMBER
4. YOUNG FARMER LEADERSHIP AWARD
5. BLUE/GOLD AWARD
6. ELMO MEYER OUTSTANDING BREEDING AWARD
7. Member of the Month
**Students may apply for Proficiency awards, Lone Star FFA Degree, and Star Awards beyond the chapter level based upon their completed record book for their FFA experience. Requirements for these awards are located in the National FFA Manual and the Texas FFA Degree Selection Procedures. This information is kept on file in the Agriscience teacher’s office. Please contact Ms. Hartman or Ms. Beasley or Mr. Lux if you wish to apply for advanced awards or for further information.
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Scholarship Opportunities
The 2011Graduating Schulenburg FFA members were awarded over $43,250.00 in FFA related scholarships!
1. Scholarship Opportunities through Texas FFA Association Scholarship Programs Graduating seniors apply during the Spring Semester at the District Degree Check. Scholarship is
based on academic rank (must be in top 25% for Houston, top 50% for the others), SAT/ACT scores (minimum 950 on SAT, minimum of 20 on ACT), and FFA activities. Students will interview at the Area Degree Check. Ten members from the Area Association will advance to state interviews to compete for these awards.
San Antonio Livestock Show $16,000 Star of Texas Livestock Show $15,000 Houston Livestock Show $15,000
o You do not have to be an Agricultural or Life Science Major to receive this scholarship. Dick Wallrath Scholarship $10,000
o You do not have to be an Agricultural or Life Science Major to receive this scholarship. Jim Bob Norman Memorial $10,000 C.J. “Red” Davidson $4,000 Southwestern Exposition $4,000 Farm Credit Bank of Texas $2,000 Texas Agricultural Education Fund $2,000 Young Farmers of Texas $2,000
2. National FFA ScholarshipsGraduating seniors apply for various scholarships. Students may obtain an application from www.ffa.org , the National FFA website. Eligibility requirements and award amounts are listed as well.
3. State Fair of Texas ScholarshipGraduating seniors must complete an application and submit it prior to deadline. More information can be obtained at www.bigtex.com.
4. Agriscience Fair CompetitionThe Agriscience Fair offers the opportunity for members to demonstrate their Agriscience abilities through a science fair competition. Scholarships are awarded on the state and national levels.
5. Proficiency, Star Awards and Work Based LearningStudents can obtain various scholarships through participation in advanced awards. Students who win on the state and national levels will receive scholarships.
6. Career Development EventsStudents can win various scholarships at various contests if they win high individual honors. Additionally, colleges scout judging team members and offer those students with exceptional abilities scholarships to judge at their universities or colleges, respectively.
7. Schulenburg FFAGraduating senior members of the FFA chapter can apply for the local chapter scholarships to help defray expenses of higher education.
8. Schulenburg Jr. Livestock ShowGraduating seniors that have participated in the Livestock show are eligible to apply for these scholarships.
9. Schulenburg Young Farmers
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Graduating seniors can apply for this local scholarship to help defray expenses of higher education.
*** Other scholarship opportunities will be announced during class and at FFA meetings as they become available. ***
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Schulenburg FFAScholarship program
Our chapter officers have decided to institute a new scholarship program this year. This new program was established to reward active membership with some scholarship money at the end of the member’s FFA career.
Points will be awarded to students every year for participating in FFA activities at the chapter, district, area, state and national level. It is the responsibility of the member and the chapter to keep a record of activities throughout the member’s FFA career.
The number of points earned by a student every year will be added up at the end of the student’s senior year. The student must have earned at least 200 points to receive the minimum scholarship amount of $100.00. For every additional 100 points the student will be rewarded another $50.00. The maximum amount of scholarship money a senior can receive is $200.00 unless the student is a 4 year Schulenburg FFA member and has earned at least 100 points each year, then that student will receive a scholarship of $250.00.
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Competitive Team Activities
Leadership Development Teams – Fall Semester Jr. Chapter Conducting Sr. Chapter Conducting Jr. FFA Skills Demonstration Sr. FFA Skills Demonstration Jr. FFA Quiz Team Sr. FFA Quiz Team Sr. Creed Speaking Jr. Creed Speaking Agricultural Issues Forum Radio Broadcasting Team FFA Public Relations Job Interview
Career Development Teams – Spring Semester Soil and Water Stewardship Speaking Extemporaneous Speaking Jr. Prepared Public Speaking Sr. Prepared Public Speaking Wildlife Land Evaluation Livestock Judging Horse Evaluation Dairy Cattle Judging Floriculture Nursery Landscape Farm Business Management Poultry Judging Ag Sales Agricultural Communications
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LEADERSHIP ACTIVITIES
The following activities are offered to all members in the Schulenburg FFA. Some activities may have prerequisites based upon leadership achievements.
Fall Semester Advanced Leadership Academy 360° Leadership Training 212° Leadership Training Area III Greenhand Leadership Camp District IV FFA Meeting State Fair of Texas Fayette County Fair National FFA Convention Leadership Development Events
Spring Semester Elite Conference Career Development Events Fort Worth Livestock Exposition San Antonio Livestock Exposition Houston Livestock Show and Rodeo Star Of Texas Livestock Show and Rodeo Schulenburg Jr. Livestock Show District IV Convention Area III Convention
Summer Break State Leadership Conference for Area and State Officers Area III Leadership Conference for District Officers District IV Leadership Camp for Chapter Officers State FFA Convention Washington Leadership Conference
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When you look good...The FFA Looks Great!
FFA Code of EthicsWe will conduct ourselves at all times in order to be a credit to our organization,
chapter, school and community by: Dressing neatly and appropriately for the occasion Showing respect for others and being courteous at all times Being honest and not taking unfair advantage of others Respecting the property of others Refraining from boisterous talk, swearing and other unbecoming conduct Demonstrating good sportsmanship Attending meetings promptly Taking pride in our organization and its functions Sharing with others experiences and knowledge by attending state and national
meetings
Official DressThe uniform worn by FFA members at local, district, area, state, and national functions is
called official dress. It provides identity and a distinctive, recognizable image to the organization.Female members should wear: Male members should wear:Black skirt – hem should be between knee and calf Black pants or slacksWhite collared blouse White collared shirtOfficial FFA scarf Official FFA tieBlack nylon hosiery Black socksBlack dress shoes – closed toe and closed heel Black shoes (low top dress shoes)Official FFA Jacket – zipped to top Official FFA Jacket – zipped to top
CDE Dress for contests Buttoned down or Polo type collared shirt Nice Jeans or Slacks that fit at the waist and are free of fading or holes. Closed toe shoes are required Appropriate caps or hats for the contest
Official Dress for Livestock Shows Buttoned down or polo type collared shirt Nice Jeans that fit at the waist and are free of fading or holes. Closed toe shoes are required – NO Tennis Shoes. Belt should be worn No caps or hats Hair should be pulled away from face and look orderly.
In addition to the previous guidelines, the Schulenburg ISD Student Dress Code is in effect at all FFA activities and competitions. If it is inappropriate to wear to school, it is inappropriate to wear to an FFA activity.
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Agricultural Science & Technology Course
OfferingsSchulenburg High School
Principles of Agriculture Agricultural Mechanics* Blinn Welding Wildlife Management Livestock Production Advanced Animal Science Food Technology Professional Communications Professional Standards in Agriculture Problems and Solutions (Yearbook) Floral Design Horticulture Diversified Career Preparations
* All Agricultural Mechanics students must provide materials for personal projects.
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FFA FUNDRAISING ACTIVITIESThe FFA provides many activities throughout the year that require money. The entry
fees for contests, community service projects, the food and refreshments at meetings, animal
projects assistance, and supplies for the banquet require a large sum of money. You are asked
to participate in whatever fundraising activity that we have. The more money that our group
makes, the more activities we can provide to you. Each family is asked to have the first member
of the family sell 25 items and 10 for each additional family member.
This year, as in the past, we are selling nutritional food products. We will be offering
DJ’s meat items and Seitz’s fruit. These products will be delivered in time for Thanksgiving and
Christmas orders. We will also be selling cheese items as well this year. These products are also
great for selling to large businesses and families for Christmas presents.
In addition, you must sell at least 25 items to be eligible to go on the end of the year
trip. The student or family that is the FFA’s top seller will receive $100.00, 2nd place will receive
$75.00, and 3rd place will receive $50.00. For Jr. FFA members, first place will receive $50.00
and second place will receive $25.00
The FFA will also be in charge of the concession stands for all home football
games. We encourage everyone to come and help out at the concession stands. The FFA will
also host its annual BBQ chicken dinner in January and run the Hamburger Stand at the Rodeo
during the Schulenburg Festival. We need all members and parents to be actively involved in
fundraising in order to fund all of our activities throughout the year.
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FFA Member ParticipationEvery FFA member should take advantage of the variety of activities that the FFA
has to offer. We will recognize those members of the FFA who have actively participated in the many activities offered. Each different activity that an FFA member participates has a point value. This system will also be used to determine what members can qualify to participate in the Schulenburg Livestock Show, Major Livestock Shows and to attend Area and State FFA Conventions, or be eligible to run for a chapter office. It will also be used to help select the various star awards. 75 Points are required to participate in the Stock show and attend the State and Area FFA Conventions.
Sign in sheets will be at each activity held, please make sure you sign your name on the sheet to receive credit. The students of the Schulenburg FFA Chapter work each year to earn a spot on the San Antonio Spurs Night Trip, by completing their required hours in the Football Concession stand. Members can earn a spot on the trip through their activities during the year. The members that earn 100 points during the year will be eligible to attend the end of the year trip. The only cost to the member is for food and souvenirs. 100 point club members will be recognized at the banquet each year.
Activities: Chapter Meetings Fundraisers (Concession Stands, Meat/Fruit/Cheese Sales, BBQ Chicken Dinner) District FFA meetings Area Convention LDE’s-District, Area and State Local FFA activities CDE’s Exhibiting Animals at Major Livestock Shows (Fayette County Fair, State Fair, Fort
Worth, San Antonio, Houston, Schulenburg Jr. Livestock Show, and Star of Texas)
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Schulenburg FFA Points ProgramHow to Earn Points:To be eligible to show in the Schulenburg Jr. Livestock Show, members must earn 75 points by participating in FFA Activities. Below is a list of activities. Not all activities are listed on this page. Feel free to add approved activities in the blanks. 1 point will be rewarded for each hour worked at the concession stand, BBQ chicken dinner tickets, work shifts, meetings or any local events. 5 points will be rewarded for each Invitational, District or Area Event, 10 points for each State or National event, with 10 points being rewarded for advancement in competition.
Concession Stand – Members must work a minimum of 12 hours (This year we will have 4 Friday Football Games and 7 Thursday JV/JH Football Games. The concession stand will open earlier on Friday nights to accommodate Volleyball patrons.)
Activity Point Activity PointConcession Stand (festival) Major Livestock ShowsConcession Stand (Football) Pre ShowBBQ Chicken Dinner Tickets Schulenburg Jr. Livestock ShowBBQ Chicken Dinner Work Shift Jackpot ShowsFruit/Meat/Cheese SaleFFA Meetings –must attend 6 District IV Greenhand Meeting
Area III Greenhand CampLeadership Development Events (D)Advancement District IV Elections/BanquetLeadership Development Events (A) Area ConventionAdvancement State ConventionLeadership Development Events (S) National Convention
Career Development Events (I) Officer RetreatCareer Development Events (A) District IV Leadership CampAdvancement Area III Leadership CampCareer Development Events (S) Advanced Leadership Academy
212/360 Leadership TrainingSpeaking Events (d) Elite ConferenceAdvancement Washing ton Leadership Conference
Speaking Events (A)Advancement Other Activities:Speaking Events (S)
Community Service Activities:
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Total Number of Points: ___________
Schulenburg FFA History
Schulenburg FFA was charted October 22, 1930. Throughout the chapter’s history,
members have been competitive in all aspects of FFA. Schulenburg boasts several state,
area and district officers. Members today are continuing to follow in the footsteps of
excellence that have lain before them.
FFA DuesSchulenburg ISD is participating in the Affiliation Fee program offered through
National FFA. This program pays the FFA dues for every student enrolled in an Ag
Science Classroom in grades 9-12. Jr. FFA is not involved in this program and will have
dues of $15.00 per member.
FFA JacketsFFA Jackets can be purchased for $60.00. This will include your jacket and a tie or
scarf. Orders will be placed on the 1st Friday each month throughout the year and the
orders will then be placed with the National FFA Supply Service. Please allow 4-6 weeks
for delivery. All members are encouraged to purchase an FFA Jacket.
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Useful LinksThe following are links to FFA pages and stock shows throughout the state. Schulenburg FFA has a page on Facebook and asks that all members and parents with a Facebook account search for Schulenburg FFA and “LIKE” the page so that you can receive updates and news.
FFAwww.schulenburg.ffanow.org
www.area3.ffanow.orgwww.texasffa.org
www.ffa.orgwww.judgingcard.com
www.theaet.com
Stock Showswww.bigtex.orgwww.fwssr.com
www.sarodeo.comwww.hlsr.com
www.rodeoaustin.comwww.sanangelorodeo.com
Agriculturewww.fb.org
www.txfb.orgwww.weather.com
www.usda.govwww.agriclutre.comwww.agr.state.tx.us
www.tpwd.state.tx.ushttp://cipm.ncsu.edu/agvl/
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AUGUST22= Back to School Rally27=First Day of School29-31=Fayette County Fair29= Young Farmer Hay Show
Mtg. 30=Officer Lunch31= College Station(V)(PN)
SEPTEMBER1-3= Fayette County Fair3= School Holiday6-=St. Joe (JV)8= Colorado Co. Fair
Livestock CDE10=District IV Greenhand
Meeting - Columbus10=FFA/Jr. FFA Meeting
(7:00) Supporter Mtg. 6:30pm
10-14= Greenhand Week12=SJLS Board Mtg. 7pm (Expo)13=Shiner (JV)14=Officer Breakfast15=Livestock Show
Supporters Lamb/Goat Show 9:00am Expo
19=Adopt A Highway
20-=Flatonia (JH) 21=Flatonia (V) (H)25=Young Farmer Mtg.
7:30pm Expo27= Johnson City (JH)27= Officer Lunch28=Johnson City (V) 29= Area Greenhand Camp
OCTOBER4=Randolph (JV)5-7= Heart of Texas Heifers11= Blanco (JH)11-13= Heart of Texas Heifers11-13= Heart of Texas Dairy12= Blanco (V)15 =Tag In
(Sheep, Goats, Pigs) 15- Jr. FFA Due Deadline18= Rogers (JV)19 =Officer Breakfast20 =FFA Lock In23= Young Farmer Mtg.
7:00pm Expo24-27= National FFA Conv.
Indianapolis
NOVEMBER1=Jarrell (JH) 2=Jarrell (V)5= Major Show Sign Up -Expo
5= FFA/ Jr. FFA Meeting (7:00)Stock show Picture
Supporters Mtg. 6:30pm Expo
8=Lexington (JV)12= District IV LDE Blinn
Brenham16= Officer Breakfast17= Area III LDE Blinn
Brenham22=Thanksgiving27= Young Farmer Meeting
7:30pm Sale Barn29 =Officer Lunch30 =State LDE
DECEMBER1= SJLS Pre show1 =STATE LDE5= Adopt A Highway10= FFA/ Jr. FFA mtg. 7:00pm Expo Supporter Mtg. 6:30pm
Expo12=Broilers arrive/Rabbit tattoo25=Christmas
JANUARY9= Stock show Board Mtg
7:00pm Expo
10-13 =Young Farmer Convention – Sugarland11= Elite Conference and Mid Winter Conference-
Brenham
14= Ford Scholar Application Due18 =Officer Breakfast22=Young Farmer Mtg.
7:00pm Expo25- 26 =Schulenburg Jr.
Livestock Show31 =Officer Lunch31=Katy Invitational
FEBRUARY2 = Klein Alumni Invitational6-24= San Antonio
Livestock Expo6= Adopt A Highway6=Stock Show Board Mtg.
Expo Center 7:00pm
11= FFA/Jr. FFA Mtg. 7:00 Expo Stock show Supporter
Mtg. 6:30 Expo15=National FFA Scholarship Application
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18-22= National FFA Week26=YF Meeting28=Officer Meeting
MARCH 1= Officer Meeting1-18= Houston Livestock
Show4= Stock Show Supporter
Mtg. 6:30 pm Expo11-26 =STAR of Texas Fair and Rodeo13= SJLS Board Mtg. 7:00pm (Expo)12-16= Spring Break20=McLennan CDE21= Tarleton CDE22=TX State Invitational CDE23=TAMU CDE Clinic26=YF Meeting28=Officer Meeting
APRIL6= Area III CDEs 6= Ingram Wildlife Invitational8= Adopt A HighwayFFA /Jr. FFA Meeting 7:30 Stock Show Supporters 8= Region III Wildlife CDE
10= SHSU CDE Invitational10=Area III Dairy @Tarleton12= Officer Breakfast15= Ambassador, Chorus, Chronicle Application deadline15=State Wildlife Contest – Childress18=Tarleton State CDE20=Texas Tech CDE23= YF Meeting24=Chapter Officer
Interviews29=District IV Banquet (elections, speaking record books) Weimar30=All Stock Show Record
Books Due
MAY2=Officer Meeting4=SHSU State CDE5 =State CDE @ TAMU6= FFA Banquet8= SJLS Board Mtg. 7:00pm (Expo)18 =Area III Speaking Events
Brenham18 =Area III Convention31= Graduation
JUNE 12-13=State Degree Check11=Stock Show Supporters
Expo 6:30 pm12= SJLS Board Mtg. 7:00pm (Expo)17-19 = Area III Camp 19=YF Meeting
JULY 8-12 =State Convention
Dallas, Texas9=Stock Show Supporter
Mtg. 6:30 pm Expo Center
29-31= Ag Teacher’s Conference (Corpus Christi, TX)
AUGUST1-2 = Ag Teacher’s
Conference (Corpus Christi, TX)
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Overnight TripsThe opportunity to participate in the Schulenburg FFA is a privilege extended to
SISD students. Participation in the Schulenburg FFA places a student in a position of recognition and often bestows the position of role model upon the member. Any student who elects to accept the privilege of participating in the Schulenburg FFA must recognize that he/she is a representative of the school and district, and will be held to a higher standard of conduct than that applied to the general student body. This applies to school related and non-school related activities. The member is subject to state law, school district policies, school rules and regulations, the Schulenburg FFA Constitution and By-laws, and University Interscholastic League (UIL) rules. Schulenburg ISD policy governs all trips taken by FFA members. Any student found in violation of these policies will be disciplined accordingly.
Students will follow directions given by Advisors, as well as adult chaperones.
Students will conduct themselves in a proper manner at all times.
Students will stay with the group at all times.
Students will not leave the hotel or site of activity for any reason.
Students will follow all curfew times. Lights out will be at the discretion of the advisors.
Students must stay in the room assigned to them.
Female students will not be allowed in rooms of male students. Male students will not be allowed in rooms of female students.
Students will wear official dress, except when notified by the Advisors. Schulenburg ISD dress code is in effect at all times.
Violations to these guidelines will not be tolerated.
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Forms
The following pages contain forms that need to be returned to the Agriscience
teachers. If you are going to participate in any FFA activity, we must have the
permission slip and emergency information. We also need the website permission form
so we may include you picture on the FFA website which is located under the
Schulenburg Independent School District website. Finally, the Acknowledgement form
indicating you have received the handbook needs to be completed and returned to your
Agriscience teacher by October 14, 2012.
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SCHULENBURG FFA / AGRISCIENCE DEPARTMENT PARENT TRAVEL PERMISSION FORMFACULTY SPONSORS: SHAYE BEASLEY, AMY HARTMAN, BRAD LUX
STUDENT: ______________________________________ GRADE LEVEL: __________PARENTS’ NAME___________________________________________________________
The above named student has my consent to travel to and/or from each event participated in by this organization during this school year including all errands and activities related to duties and assignments made to members enrolled in the FFA / AGRISCIENCE CLASS. The mode of transportation will be Schulenburg ISD provided transportation.
1. All students must abide by state, district and campus policies at all AGRISCIENCE/FFA sponsored events, whether held during normal school hours, after school hours, or on weekends and holidays.
2. I understand that students who violate said policies will be subject to disciplinary consequences in accordance with the STUDENT CODE OF CONDUCT, including possible removal from future participation in FFA events.
3. I understand that infractions to any of these said policies which include theft, vandalism, and possession of illegal substances will result in notification of parent/guardian and my child being returned to school at the parent’s expense with no reimbursement of funds.
4. I agree to, and hereby, release Schulenburg Independent School District and its trustees, employees, sponsors and volunteers from all legal responsibility from liability resulting from any activities of this organization, including liability caused by or related to the negligence of any such party.
5. I agree or do not agree (please circle one) to allow my child to swim at any events that swimming opportunities available.
6. I agree or do not agree (please circle one) to allow my child’s name and picture to appear on the Schulenburg FFA web page or in articles in the newspaper.
This form must be signed and returned to the sponsor before the student will be permitted to participate in any activities of this organization. This Schulenburg FFA & Agricultural Science Department Handbook has been published to help your son/daughter gain the greatest possible benefit from his/her agricultural science/FFA experience. The FFA needs your cooperation. It is very important that each FFA member understands the opportunities and regulations outlined in this handbook. Parents are to encourage their son/daughter to abide by all rules or regulations set forth in this handbook. Please go over all agreements outlined in this handbook and return them to your Agriscience teacher. Your signature and that of your child acknowledge the receipt of this FFA Member Handbook and the agreement to take full advantage of all the opportunities that are available to members.
__________________________________________ ___________________Signature of Student Date
__________________________________________ ___________________Signature of Parent Date
Date Received______________________________
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Schulenburg FFA Emergency InformationThis form must be completed by the parent/guardian of each member. This form is required of all students in an Ag Science Class. This form must be updated yearly or in the event that any of the information should change. WITHOUT THIS COMPLETED FORM, YOUR CHILD MAY NOT PARTICIPATE IN THE FFA ACTIVITIES.
STUDENT’S NAME_____________________________________________ GRADE______
DATE OF BIRTH_____________________ T-Shirt Size: _________
PARENT OR GUARDIAN’SNAME________________________________________________________________________
HOME ADDRESS_________________________________ CITY_________________________
ZIP____________
TELEPHONE #__________________ PARENTS HOME # (IFDIFFERENT) ___________________
MOM’S WORK #_____________________ DAD’S WORK#_______________________________
Parent’s Email Address____________________________________________________________
INSURANCE CARRIER____________________________________ _____________________PHONE #_____________________________________________________________________NAME OF INSURED____________________________________________________________ID NUMBER___________________________________________________________________GROUP #_____________________________________________________________________PLAN #_______________________________________________________________________
Name and phone number of relative or friend who can be contacted in case of emergency whenParent/guardian is unavailable.NAME_________________________________________ PHONE #_____________________RELATION__________________
NAME_________________________________________ PHONE #_____________________RELATION__________________
FAMILY DOCTOR_______________________________PHONE#______________________
DENTIST_______________________________________PHONE#______________________
IF, IN THE JUDGEMENT OF ANY REPRESENTATIVE OF THE SCHOOL, THE AVOVE STUDENT NEEDS IMMEDIATE CARE AND TREATMENT AS A RESULT OF ANY INJURY OR ILLNESS, I DO HEREBY REQUEST, AUTHORIZE, AND CONSENT SUCH CARE AND TREATMENT AS MAY BE GIVEN SAID STUDENT BY ANY MEDICALLY QUALIFIED REPRESENTATIVE. I DO HEREBY, AGREE, TO INDEMIFY AND SAVE HARMLESS THE SCHOOL AND ANY SCHOOL REPRESENTATIVE FROM ANY CLAIM BY ANY SUCH PERSON OF SUCH CARE AND TREATMENT OF SAID STUDENT.
___________________________________ __________________________________STUDENT’S SIGNATURE DATE PARENT SIGNATURE DATE
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