Metropolitan Preparatory Academy

And High School Unplugged

2013 Application Form and Health, Contact and Permission Forms

SUMMER IN GUATEMALA APPLICATION 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 Adrienne@highschoolunplugged.com.

STUDENT AND FAMILY CONTACT INFORMATION Todays 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 Telephone: Province Home ____________________ Cell_________________ Postal Code

Email Address: _____________________________________________ Legal Guardian/Parent Number One:

First Name

Last Name

Relation to Student: _____________________________ Complete Street Address: Number and Street City Home Telephone: ( Work Telephone: ( Mobile Telephone: ( Province Postal Code

) __________________________ ) __________________________ ) __________________________

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: Students 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:_________________ 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. Date___/___/___/
D M YY

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 Adrienne@highschoolunplugged.com , along with the following required attached documents:
An electronic scan (PDF or JPG) of your child/dependents 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 INFORMATION Please indicate any of the following that apply: Kosher Vegetarian Vegan Lactose Intolerant Other (please provide details below) Details/Comments:

STUDENT ALLERGY INFORMATION Please indicate any of the following allergies that apply and provide details: Hay Fever Insect Stings (please provide details below) Drugs (please provide details below) Food (please provide details below) Other (please provide details below) Details/Comments:

STUDENT HEALTH INFORMATION Please 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? so, please provide details: 2. Is your child/dependent on any medications? and dosages. medications with him or her to Guatemala. 3. My child/dependents blood type is: 4. Please indicate any additional comments or concerns. If so, please provide all details If

Please note that your child/dependent must bring all

HEALTH CONSULTATION CERTIFICATION

It 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. section, you both you and the health provider certify that you have done so. stamp and signature of a licensed health professional is required. In this The

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 In the event a correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed activities unless specifically noted. 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 STAMP I 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 students participation. a trip to Guatemala. Name, Title, Institutional Affiliation, None of my professional advice counter-indicates participating in ___________ ____________

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: sign. This is a release of your legal rights. Read and understand this document before you

If the student has more than one legal guardian, both are required to sign.

Parent/Guardians Name: _________________________________________________________________________

Last

First

Middle

Parent/Guardians Name: ________________________________________________________________________

Last
Traveling Students Name:

First

Middle

_________________________________________________________________________

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. these risks. I have made my own investigation and accept

I understand that High School Unplugged is not responsible for matters that are I hereby release High School Unplugged and its legal representative(s)

beyond its control.

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/dependents 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 childs school, the ultimate arrangement of academic credit for participation in the program is dependent upon my child or dependents 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 years 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 dependents 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. drug use are prohibited. Leaving the group is prohibited. Drinking and

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 dependents 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 dependents 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 To the

assume all the risks and responsibilities surrounding participation in the Program.

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 dependents 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:

______________________