Warrior for a Day Application

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warrior for a day application (Student Shadowing)

Please fill out the following form (one form per student), and our Director of Admissions will contact you with further details.
Parent's First and Last Name: *
Parent's Cell Number: *
Address *
Address 1
Address 2

City

State

Zip
Student's First and Last Name: (one per form) *
Student's Gender: *
Male Female
Current Grade in School: *
Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
Are you considering a move in the current school year or next school year? *
Current school year Next school year Not sure
All Warrior for a Day students will be paired with a Watersprings School student of the same gender in the same current grade. Does your child already know a specific student in his/her same grade with whom he/she would wish to be paired? Due to schedules and other constraints, we are not able to accommodate all requests.
Does your child have a diagnosed learning difference and/or receive any accommodations?
Yes, my student has a diagnosed learning difference and/or receives accommodations. No I have some concerns, but nothing has been officially diagnosed.
Does your child have a severe allergy that requires a prescription EpiPen?
Yes No
If yes, please have your child bring an EpiPen with him/her on their scheduled shadow day and give it to the school secretary upon arrival.
Does your child have asthma and use an inhaler? *
Yes No
If yes, please have your child bring an inhaler with him/her on the scheduled shadow day.
Does your child have any other allergies or medical conditions? *
Yes No
If yes, please describe - if no, type NA *
If the answer to the above question is "yes," do we have your permission to share the information you've provided with our office staff and faculty?
*
Yes No
Emergency contact information (list name and cell number) *
MEDICATION RELEASE: I understand that over-the-counter medications must be in their original container and labeled with my child's name. I understand that prescription medications must be in their original container including the pharmacy label with the child's name and dosage instructions. Type "YES" below:
*
MEDICAL RELEASE: If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them above. In the event an emergency occurs, I may be reached at the telephone number listed on this form. If I cannot be reached, I hereby authorize Watersprings School to make emergency medical decisions for my child. Type "YES" below:
*
AGREEMENT AND RELEASE FROM LIABILITY: Except to the extent of damages caused by the gross negligence or willful misconduct of Watersprings School, I hereby agree to indemnify, release, and hold harmless Watersprings School, its officers, directors, and employees, and any other organization co-sponsoring the school's Warrior for a Day program, from and against any and all liability or injuries which I or my child may suffer arising out of or in any way connected with my or my child's participation in the Warrior for a Day program. In case of emergency, arising during or in connection with any activity, I authorize any person in charge of the activity to consent to emergency care, at my expense. I understand that Watersprings School is not obligated to carry any insurance to cover medical and/or dental treatment for me or my child. I agree to pay any damages or expenses incurred by Watersprings School due to my or my child's negligence or disregard of the rules of the school. Type "YES" below:
*
Date Label *
Signature (by digitally signing this form, I consent to the releases listed above): *
If you have other children who would like to be a Warrior for a Day, please complete a separate form for each child.
Enter Your Email Address: *

warrior for a day application (Student Shadowing)

If you have other children who would like to be a Warrior for a Day, please complete a separate form for each child.