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Name: ____________________________________________________ Period: _____________ Used for:Medical Skills (MS)Health Science Anatomy (HSA) Health Science Foundations (HSF) Principals of Public Safety (PPS) Fire Fighting 1, 2&3Academic Cohorts:Anatomy Medical & Fire InstructorsS. Hill (Medical) susan.hill@polk-A. Matthews (Medical) ana.matthews@polk-K. Hubbard (Medical) Cell-863-287-3135 kozette.hubbard@polk-K. Miles (Fire) kenneth.miles@polk-A. Willard (Fire) amanda.willard@polk-J. Huff (Fire) Jennifer.huff@polk-B. Saunders (Fire) William.saunders@polk-Academic InstructorsA. Allison (Anatomy) adele.allison@polk-The Medical and Fire Academy offers a series of courses in the Medical & Fire Science program. Each course builds on the previous to complete the Gold Seal Vocation Program in Health and Fire Sciences. Each course is a full year and upon successful completion of each course you will receive one honors elective credit towards Bartow High School (BHS) graduation requirements. You will end the program by taking the State or National certification exam. These exams include Certified Nurse Assistant (CNA) Home Health Aide (students do an extra 32 hours at a extended care facility as a volunteer) Exam, EKG National Exam, Fire Fighter 1, and National Registry Exam (NREMT). Students have the option of also taking the credit by exam at PSC or the NREMT exam and present the certificate to PSC for credit. Students will have the option of sitting for the PSC Cardio vascular EKG Exam for three semester hours to be applied to the Cardiovascular Technician (CVT) Program. Student’s completing Firefighter 1 and EMR may also present their certificates to South Florida State College and receive college credit and may enroll into Firefighter 2 and EMT at the Avon Park Campus. The primary objective of each course is to further orient students to a Medical, and Fire Careers. During each class students will be exposed to various medical and fire related issues, both traditional and non-traditional. We will also prepare students to continue into one or all of the upper level courses (Emergency Medical Responders, Certified Nursing Assistant, Electrocardiograph Technician (EKG), or Fire Fighter 1. Students will leave with knowledge and experience that will enable them to obtain gainful employment in the medical and public safety field. Students will also be taught to conduct themselves in a professional manor. They are expected to have the moral and ethical compass needed to join these professions. If they cannot conduct themselves in this manor they will 0Parents and students please initial next to the rule in the line provided.RULES and EXPECTATIONSClassroom Code of Conduct______/______ the responsibility to provide any materials, excluding text and workbooks, which are required as part of the course curriculum lies solely with the student. ______/______ Classroom atmosphere and/or student behavior are determined according to the course instructor’s discretion. In the event that a course instructor determines a student’s conduct is inappropriate; said student will be asked to leave the classroom at once and may be sent to the Learning Resource room or Discipline. In addition, the student will have to meet with the instructor prior to returning to class. ______/______ any injury incurred while taking part in a related function must be reported to a Bartow Medical and Fire Academy representative promptly. ______/______ Students are not to enter any office area unless there is a staff member present and prior authorization to enter said office has been granted. ______ /______Smoking is NOT allowed within any of campus buildings or campus this includes E-cigarettes. ______ /______the use of the phone system is strictly limited to business related staff use only. ______/______ the use of electronic devices such as pagers, cell phones, and laptops is strictly prohibited while classes are in session (this includes skills and simulation labs). Furthermore, any electronic device in your possession must be turned off and kept out of sight. ______/______ Failure to comply with the electronic device policy will result in the following: 1st offense will result in a verbal waring from the instructor. 2nd offense will result in the student being removed from the room. 3rd offense will result in possible suspension from the academy program. (An offense is described as any time the device is visible to a staff member or reported to Academy staff by a schoolboard staff member.) ______/______ All program students are subject to disciplinary action if it is determined, they have in anyway participated in the distribution and/or disclosure of any pictures, videos, and/or any other form of communication deemed to display or disclose immoral, indecent, illegal, unethical or otherwise inappropriate material. If said disclosure relates to, and/or was acquired in conjunction to the students’ course of study while a part of the program. ______/______All students are asked to respect the rights, privacy and dignity of all those with whom they interact as a program student. All students should conduct themselves appropriately at all times. ______/______ Any student/s who, at the sole discretion of the instructor, violates the above rule is/are subject to dismissal from the program. ______/______ the consumption and/or possession of any alcoholic beverage and/or controlled substances, whether legal or illegal, is strictly prohibited not only on every campus, but at all clinical rotation locations as well. In addition, students must NOT be under the influence of alcohol or other controlled substances at any time during which they are representing the Medical and Fire Academy Programs. This includes on and off campus locations. Violation of this rule will result in disciplinary action up to and including immediate dismissal from the program. Dismissal may occur immediately or at the end of the academic year.______ /______Violations of the Student Code of Conduct will result in a Student Counseling Form being generated. This form is composed of two (2) groups which are separated by the penalty which will be applied: Group one (1) offenses are serious infractions, which are associated with the potential for adverse Criminal consequences. Any group one (1) infraction will result in an immediate dismissal from the Program. (Re-admission may not be possible) Group two (2) offenses most often relate to procedural infractions and follow a three (3) “strike” rule as Follows: First offense = Verbal Reprimand Second offense = Written Reprimand Third offense = Dismissal from the Program. Dismissal may occur immediately or at the end of the academic year.______ /______Group 2 offenses signify a reprimand in steps for dismissal. You in fact may receive 1, 2 or all 3 reprimands at one time depending upon the offenses being disclosed by the Program staff. ______/______ lastly, the following persons may ask a student to leave the classroom area at any time they deemed it to be necessary: Program Medical Director - Dr. Joe Nelson Program Director – Kozette Hubbard Program Instructors – Any Staff Member Program Visiting Instructors and /or Clinical Instructors _______/_______Fighting Fighting is NOT tolerated in the Medical and Fire Academy. If you are found to have instigated or were the aggressor in a fight you will be removed from the Medical and Fire Academy immediately. _______/_______Rudeness and insubordination All students of the Bartow Medical and Fire Academy will conduct themselves in a civilized manner. We will not tolerate students being rude to other students or to staff. We will not tolerate insubordination. All of this will get you removed from our academy. Medical and Fire are SERVICE organizations. We do the job because we want to help others, not because we are wanting to be heroes or rich. Conduct yourself accordingly. _______/_______Absences The teacher will contact the parent/guardian after three unexcused absences in a row. Students will have the opportunity to make up any work if absences are excused. (Note- excessive school absences may result in loss of credit and the department will follow the PCSB Student Code of Conduct.) It is the student’s responsibility to make arrangements with the teacher following an absence. The student will have the number of days absent to complete and submit the work for credit. If a student has a history of excessive absences it may affect the student chances of staying in the Academy. After 4 unexcused absences, any make-up work is up to the teacher’s discretion on a case by case basis. _______/_______Seat Hours Active participation in the class is required. Students cannot learn if they are not present. A student who misses greater than twenty percent of class may not be permitted to move on to the next level. If a student has an excusable need to miss greater than twenty hours, it is the responsibility of the parent to contact the instructor. NO EXCUSES!!!!!! _______/_______Tardy In the professional world, being late for work is unacceptable. Thus, we expect all students will be on time and in their appropriate seats when the tardy bell rings. If you are late you will be given a referral. (This follows the PSCB Code of Conduct tardy policy and the BHS tardy policy)_______/______Sleeping There is a strict no-sleeping-in-class policy in the Medical and Fire Academy. _______/______Cell Phones, I Pods, MP3. Cell phones are not permitted to be used in class for calls, texting, or listening to music. They are to be on silent and put away from view in a backpack or pocket. IPod and MP3 players are not permitted to be used in class. You will have a discipline referral written up and you will be sent to the discipline office. _______/_______Disciplinary actions Parent or guardian contact is an option available to the instructor at any time. It is preferred to have a student/teacher discussion before involving parents. If a solution cannot be agreed to, the instructor will contact & involve the parent or guardian. If the infraction is severe enough, school administration will be involved immediately! _______/_______Food and Drink privileges Food or Beverages are allowed in class at the discretion of the individual teacher until it becomes a distraction or if students are not responsible for their mess. Each class will be responsible for keeping the classroom free of debris. If sanitation is not maintained, this privilege for the entire class will be suspended till the end of the semester. The chewing of gum will not be permitted. _______/______Restroom privileges Students will not be allowed (unless an emergency exists) to visit the restroom during the first 10 min or the last 10 min of class period. Freeze Time (This varies by classroom and teacher as some rooms have a restroom in their rooms) Students will not be allowed out of the classroom if someone is already out. _______/_______Evaluation (Please see the grading scale of your individual teacher) An example of one type of grading protocol follows: Uniforms – 10%: are to be worn every class day, all day and a daily grade will be given. This is a participation grade and if you are absent you will receive a zero. Friday are civilian days and students are allowed to wear clothing in accordance with BHS dress code. If a student would like to receive extra credit or make up for a missed uniform grade the student may wear their uniform on Friday or on any day they do not have their medical or fire class. Wednesday is Professional Dress Day and Business attire is permitted in place of uniforms. Uniforms consist of Royal Blue Scrubs with close toed and heel shoes or Navy Blue BDU style pants with either an academy polo or BHS academies T-shirt with black shoes or bootsCertifications – 20%: for CPR, BBP, FA ECT… Skills - 10%: will performed and tested. Quizzes – 10%: will be given periodically. Unit Exams – 20%: will be given at the completion of each unit. These tests may include questions from both textbook & material covered during class time, or in Health Center 21.Health Center 21 – 10%: This is an online companion to our classes and you will be required to complete quizzes and exams that will go along with what is being taught in class. Students may work on this at home. Access will be turned off after the due date and no makeup given. You have plenty of time to finish the assignments.Term Papers and Special Projects – 20%: will be given periodically.Any student has the option of retaking any unit exams within 5 school days of the original test being given (before or after school). If the student feels they can better themselves, then the option is open to them._______/_______Homework & Assignments (Medical, Fire and Academic) Students will be given homework and out of class assignments. These assignments shall be turned in at the assigned time. If a student has an excused absence, the student has until the next scheduled class to hand in the assignment. *NO LATE HOMEWORK ACCEPTED* _______ / _______ Credit will not be given for late work (see above exclusions). You cannot give a patient medications or treatments late. If you do the patient may die…..so if you CHOOSE to turn in late work it is the same as killing a patient….YOUR grade is your patient!!! ________/_______Videos/DVDs (Medical, Fire, and Academic) In the Medical and Fire Academy we will be allowing the students to view PG13 rated films, such as Autopsy Videos, “Patch Adams” “John Q” Fire videos, You Tube, training videos. All the films will be relevant to the medical and fire realm and the lesson being taught. It is the parent’s responsibility to notify the instructor if they do not want their student viewing PG13 films. Parent Initials only in this area!! _________My student has permission to view PG13 videos/DVDs. _________My student does not have permission to view PG13 videos/DVDs. An alternative Assignment will be given. _________ Autopsy videos are often shown as a supplement to lecture. My student has my permission to view these videos. _______/_______Notebook (100pts) Each student will be required to keep a notebook. The notebook will be checked each nine-week grading period. (The formatting of the notebook varies by teacher) The student must keep all returned work, skill sheets, notes and handouts in the notebook. It is the responsibility of the student to maintain the notebook. Each class (MS, HSI, HSII, etc.) will have different requirements as to the division of the notebook (ex-Current Events-Test/Quizzes-Notes/Informational Handouts-Worksheets/Skill sheets). Points are awarded for complete, neat, and organized notebooks. Example of Sections in Notebook/Binder1. Syllabus2. Chapter Reviews/Worksheets3. Notes4. Test/Quizzes/Exams5. Skill Sheets6. Certifications_______/_______Skills Lab (Medical, Fire, and some Science classes) Various skills will be required throughout the course. Skill sheets will be given to each student to be signed by the instructor after successfully being tested on the skill. IT IS THE STUDENT’S RESPONSIBILITY TO KEEP THE SKILL SHEETS. IF THE SHEET IS MISSING OR NOT SIGNED, THE STUDENT WILL NOT BE GIVEN CREDIT FOR COMPLETING THAT SKILL. The skills will be demonstrated and the student will practice until proficient in this skill. The student will then request to be tested for competency on the appropriate skill and then will be tested. If proficient, the instructor will sign and date the skill. If unsuccessful, the student will then be requested to practice until competent and then will be tested again for competency. Additional assistance is available if necessary before and after school hours. Students will follow all lab safety rules. No open toe or heal shoes will be permitted in a lab setting. Flip flops are not allowed. _______/_______ Lab fee Medical Skills/Public Safety=10.00, HS Anatomy=30.00, HS Foundations=30.00, Fire 1,2 &3=30.00 EMR, EKG, & CNA =40.00 In order to continue to provide the high quality program, it will be necessary to charge a lab fee for all students enrolled in the Medical / Public Safety Academy. A fee of $________ per year will be assessed to cover the cost of supplies in Medical Skills, Health Science 1&2, and Fire Fighting 1&2, Criminal Justice 1-3. A fee of $_________ will be assessed for the following: CNA, EKG, EMR, and FF1. If a student is unable to pay the fee it is the responsibility of the parent to contact the teacher to make arrangements. Checks should be made out to BHS HOSA for Medical classes and BHS FPSA for Fire classes or as stipulated by teacher. _______/_______Class Material (varies by class. See individual teacher for supply list) Example of supply list:Binder (1 1/2 inch minimum)Colored PencilsNotebook dividers (5 sections)Index Cards (5x7 500 ct)Student Planner given by the schoolFlash driveCalculatorNotebook paper (non-spiral)BLACK Pen and PencilAll written work will be in black ink. No other color will be accepted!!!The format will be as follows: Top right hand corner: Students Name, Date, Period and Subject (example HSF –P1, HSA-P2 or MS–P4). _______/_______ Uniform Policy ALL of the students are REQUIRED to wear BHS Academies T-Shirt or Academy polo with scrubs or navy blue BDU style pants (examples are available from instructor) with the approved Medical/Fire Academy polo (instructor will advise of polo color) on any day that the student has a Medical/Fire Academy class. Scrubs will consist of Royal Blue pants and top. A variety of styles and cuts are available. Students may choose their own vendor. It is understood that when wearing scrubs or the complete uniform ensemble will be maintained throughout the day. All classes will adhere to the uniform policy of the BHS Medical and Fire Academy including fifth period which meets every day. It will be up to the Lead Instructors as to certain days that students may be allowed to wear regular clothing. The BHS Academies T-Shirt is accepted.Students must be in uniform while at school and must stay in uniform all day. If you are in another academy you may wear that uniform in place of the medical or fire uniform. Sumerlin students must either be in the Sumerlin uniform of the day or in the medical/fire uniform. If Sumerlin grants a civilian or jeans day the medical or fire uniform must be worn. Understand that students are required to purchase uniforms for classes and the third level classes will require a certain uniform for clinical and special details. _______/_______Continuing Education Units - Extra Credit (CEU-EC) (30 pts) Students will have the option to submit a CEU-EC once during the nine-week grading period. The article may be found in the various trade magazine/publications available in the classroom. The student must receive prior approval from the instructor. The evaluation/test must be accompanied with a copy of the article. To receive credit, a minimum score of 80% will be required. ______/________ Plagiarism, copying, or cheating Plagiarism will not be tolerated. Turning in work that is not your own without proper documentation (MLA or APA) will receive a written referral and a zero on the assignment. Copying another’s work and submitting it as your own will also result in a written referral and a zero. This includes homework, quizzes, tests and classwork, unless otherwise specified by the teacher. Academic Dishonesty Policy_______/_______This policy is intended to enhance Polk County School Boards academic dishonesty policy as outlined in the current student handbook. In the unlikely event that a conflict arises between the policies, the policy listed on the student handbook will supersede. _______/_______There is no form of communication permitted amongst students while an exam, quiz, or any other type of academic assessment tool is in use. If the need to speak with an instructor should arise, students may approach the instructor unless told otherwise. However, the student must take extra care to ensure disruptions and/or distractions are, kept to a minimum. The following outlines the Academic Dishonesty Policy as outlined in the Medical and Fire Academy and Polk Public School District student code of conduct handbook: Cheating and Plagiarism_______/_______Polk County School Board considers academic dishonesty an assault upon the basic integrity and value of an education. Cheating, plagiarism, and collusion in dishonest activities are serious acts that erode the educational role and tarnish the learning experience, not only for the perpetrators but for the entire community. It is expected that all students understand and subscribe to the ideal of academic integrity and that they are willing to bear individual responsibility for their work. Materials (written or otherwise) submitted to fulfill academic requirements must represent a student’s own efforts. The fundamental purpose of this rule is to emphasize that any act of academic dishonesty attempted by any student is unacceptable and shall not be tolerated. Examples of academic dishonesty include: 1. _______/_______Cheating or plagiarizing on tests, projects, or assignments: Cheating is defined as the giving or taking of any information or material with the intent of wrongfully aiding oneself or another in academic work considered in the determination of a course grade. Plagiarism is defined (Black’s Law Dictionary, Revised Fourth Edition) as “the act of appropriating the literary composition of another, or parts or passages of his writings, or the ideas or language of the same, and passing them off as the product of one’s own mind.” Plagiarism includes failure to use quotation marks or other conventional markings around material quoted from any specific source without citing that source, or paraphrasing a specific passage from a specific source, or using any sequence of material or order of wording without accurately quoting and citing that source. Plagiarism further includes letting another person compose or rewrite a student’s assignment. The following items have been identified, by the faculty and students, as a partial list of examples of cheating and/or plagiarism: a. Asking for information from another student before, during, or after a test, quiz, or exam situation. b. Copying answers from another’s paper during a test, quiz, or exam situation. c. Knowingly letting someone copy from one’s paper during a test, quiz, or exam situation. d. Using sources other than what is permitted by the instructor in a test, quiz, or exam situation. e. Copying material exactly, essentially, or in part from outside sources while omitting appropriate documentation. f. Copying or falsifying a laboratory report, clinical project, or assignment without doing the required work. g. Changing answers on a returned graded test, quiz, or exam in order to get the grade revised. 2. _______/_______Plagiarism in written assignments: Plagiarism also includes handing in a paper to an instructor that was purchased from a term paper service, created by another student or other individual, or downloaded from the Internet and/or presenting another person’s academic work as one’s own. Individual academic Departments may provide additional examples in writing of what does and does not constitute plagiarism, provided that such examples do not conflict with the intent of this policy. 3. _______/_______Furnishing false information to any faculty member. 4. _______/_______Forgery, alteration, or misuse of any document, record, or instrument of identification. Violations of the s policies pertaining to academic dishonesty may result in academic penalties and/or disciplinary action at the discretion of the professor. Academic penalties may include, but are not limited to, a failing grade for a particular assignment or a failing grade for a particular course. Students charged with violating the Academic Dishonesty portion of this rule are not permitted to withdraw from the course. Additionally, a student in violation of the Student Code of Conduct may be referred to the Dean of Discipline. Any student suspected of violating the Academic Dishonesty section of the Student Code of Conduct is subject to sanctions and provided due process as outlined in the Academic Dishonesty procedure. Any student found to be cheating will be subject to disciplinary action, which at minimum will result in said person receiving a grade of ZERO on the assignment underway when the alleged incident took place. In addition, the student will receive a written counseling form and a referral to speak with the Instructor and Program Director who will decide if the student will be subject to dismissal from the Program. THIS FOLLOWS POLK COUNTY SCHOOL BOARD CODE OF CONDUCT POLICY HOSA and FPSA:ALL STUDENTS ARE REQUIRED TO BE MEMBERS OF THE PROFESSIONAL ASSOCATION FOR THEIR ACADEMY. THE ASSOCATION IS CO-CURRICULAR MEMBERSHIP DUES ARE REQUIRED ONCE A YEAR. FEE: $35_______/_______ HOSA – Health Occupation Students of America FEE $35– Student Org. (Medical) HOSA is a national professional /student organization that is co-curricular and allows students to compete in various health related competitions. HOSA's two-fold mission is to promote career opportunities in the health care industry and to enhance the delivery of quality health care to all people. HOSA is actively involved in the community and has scholarship opportunities. It is required that all students in the BHS Medical Academy also join HOSA. Fees will be required for this such as membership dues, conference fee’s and so forth. Please take time to view their web site. ________/_______ FPSA- Florida Public Safety Assoc. FEE $35 Student Org. Fire and Criminal Justice FPSA is a national student organization that is co-curricular and allows students to compete in various fire and law related competitions. FPSA's two-fold mission is to promote career opportunities in the Fire and Law industry. FPSA is actively involved in the community and has scholarship opportunities. It is required that all students in the Fire classes also join FPSA. Fees will be required for this such as membership dues, conference fee’s and so forth. Please take time to view their web site. _______/_______ Polk Portal It is the responsibility of the parent/guardian to monitor the student’s grades and attendance via the Polk Portal. If there is any question concerning the students grades feel free to contact the instructor by email or by phone after school hours._______/_______If a student is given detention by an instructor of the Bartow Medical and Fire Academy this detention will be served after school from 14:00 hrs. until 15:30hrs in the academy area and with the instructor who administered the detention. Student’s will be assigned a variety of duties up to and including, washing and waxing the academy vehicles, working in the academy supply room, cleaning the classrooms and lab areas, cleaning equipment and supplies, grounds clean up in and around the academy area. The academy is not responsible for providing transportation to the student who receives detention. Failure to serve the detention or refusal to perform duties assigned during detention will result in a discipline referral being generated and the student being sent to the Discipline Office to be dealt with by administration. Students and Parents need to be aware this could include suspension for failing to follow directions given and constitutes insubordination. _______/_______Keep in mind that students at the academy are allowed many privileges that other students do not get to do. They will be allowed to participate in several events and assist with skills. All of this depends on how well the student conducts themselves in and out of class. Because all of the instructors at the academy hold certifications and licensees that the students are allowed to practice under discipline is of the upmost importance. If the academy staff cannot trust a student for any reason that student will not continue in the academy. Any student violating any policy of the academy that jeopardizes any staff member’s certification or license will be subject to immediate dismissal from the academy. We simply will not tolerate any behavior that puts another student, patient or staff member at risk. You will step up to our level, we will not step down to yours. ______/______ PARENTS!!!! You are required to take an active part in your student’s education!!!!!!! This means participating in keeping up with grades and assignment’s. You are required to sign up for parent portal thru the school along with your students signing up for student portal. Do not wait until the last day of the nine weeks, semester, or school year to do something or question the instructor as to why your student may not be doing well. KEEP UP WITH YOUR STUDENT. The instructors strive to enter grades ASAP. We also have a Facebook page that we frequently post updates to information as to what is due.Parent Signature:________________________________________________________________________________ Bartow Medical and Fire AcademyStudent Counseling FormGROUP 1()Automatic Discharge from Academy. Reporting to your class/clinical under the influence of alcohol or an illegal substance. Theft, abuse, misuse, or destruction of property. Remove or disclose confidential information without proper authorization. Immoral, indecent, illegal or unethical conduct. Possession of a weapon, threatening to use of such on clinical, school or hospital premises. Misuse or falsification of patient, student, or official clinical / hospital records. Engaging in disorderly conduct/fight that could ultimately threaten the physical well-being of any person.GROUP 2 (A)()1st Offense - Verbal Reprimand ()2nd Offense - Written Reprimand()3rd Offense - Failing Grade and Dismissal from the Program. Leaving school/clinical area without proper authorization AND / OR not completed time for that clinical. Individual acceptance of gratuities. Sleeping during scheduled school/clinical hours. Insubordination / Refusal to obey an instructor /preceptor. Inconsiderate treatment of patients, visitors, students, or school/clinical/Hospital employee. School/Clinical tardiness / absence.Failure to be ready for clinical assignment at starting time. Inappropriate dress appearance per program regulationsViolation of safety rules and regulations OR failure to use proper safety equipment. Misuse of school/clinical time. Smoking in RESTRICTED AREASAND Time not counting toward course completion. INFORMATIONALClass Tardiness Did not complete and turn in prerequisite paperwork by due date.952510858500REMARKS: 9525110490001333510541000 1333512636500 _________________________________________________________________________________________Student Signature / DateParent Signature / Date___________________________________________ __________________________________________ Instructor / DateSchool Administrator / DateSignature/Acknowledgement PageWe have read and agree to comply with all rules and requirements of the Bartow Medical and Fire Academy. We understand that failing to comply can result in dismissal from the academy. Students are to maintain a GPA of 2.0 to continue in the academy. All students are expected to maintain a professional appearance and attitude while in and out of uniform.Class (circle all that apply): MS / HSA / HSF / Fire 1Student Name (print) __________________________________ Student Signature______________________________________Date___________________________ Parent Name (print) ___________________________________ Parent Signature_______________________________________Date___________________________ Parent Email address__________________________________________________________________ Parent Cell/Home Phone ______________________________________________________________BHS Medical & Fire Academy Information Sheet School Year 18-19Teacher: Circle all that apply HillHubbardFire Inst.Last Name____________________________________ First___________________________________ MI_______Address__________________________________________________________ City________________ ZIP______ Home phone_____________________________Cell___________________________ Student Email____________________________________________________________ Parent/Guardian Name _________________________________________________________ Relationship_____________________ Address________________________________________________________ City___________________________ Home Phone______________________________ Cell___________________________ Work place _______________________________ Work Phone____________________ Email __________________________________________________________________ Parent/Guardian Name ___________________________________ Relationship_____________________ Address__________________________________ City___________________________ Home Phone______________________________ Cell___________________________ Work place _______________________________ Work Phone____________________ Email __________________________________________________________________ Medical Information Doctor___________________________________ Phone_________________________ Allergies________________________________________________________________ Medications_____________________________________________________________ Medical Problems_________________________________________________________Form No. TRNS 0082 Appendix ATHE SCHOOL BOARD OF POLK COUNTY, FLORIDABLANKET FIELD TRIP PERMISSION FORMTO WHOM IT MAY CONCERN: __________________________________________________ has my permission to participate in all field trips to Name of Studentbe taken by: Bartow Senior Medical& Fire Academy/ HOSA/FPSA during the 2018– 2019 school year. Name of organization/group As parent/guardian I acknowledge the following: 1. School officials are authorized to obtain emergency medical treatment for this student as necessary. 2. The School Board has made available to this student the opportunity to purchase student accident insurance. 3.During this field trip, that the School Board will not be liable for injury to this student as result of the negligence, errors, and omissions of others (i.e., charter bus owners and drivers, or amusement park owners or workers), their agents, heirs, employees or assigns either through their action or inaction. 4. If your child takes personal belongings on this field trip, he or she will be responsible for them. The School Board accepts no responsibility for personal items, such as watches, purses, money, cameras, and wallets, etc. If a student stores personal items in a locker at an amusement park, that entity may be responsible for any loss or damage. ______________________________________ _________________ Signature of parent/guardian Date NOTES: 1. THIS BLANKET FORM MAY BE USED FOR TRIPS OF A SIMILAR NATURE, WHICH ARE REPEATED DURING THE SCHOOL YEAR. 2. FOR ALL OUT-OF-COUNTY TRIPS, A NOTARIZED MEDICAL TREATMENT AUTHORIZATION FORM MUST ALSO BE AVAILABLE. THE MEDICAL FORM MUST BE COMPLETED PRIOR TO THE STUDENT'S FIRST OUT-OF-COUNTY TRIP AND SHOULD BE RETAINED FOR USE DURING THE REMAINDER OF THE SCHOOL YEAR. Students may have to provide transportation to and from some functions. Students are required to stay for the entire function and are not permitted to leave unless the instructor in charge of the function has been notified and the parent has given permission for the student to leave. Please sign below if you will allow your student to drive to and from all functions and leave only when the function is over. _____________________________________________ Parent Signature Form No. TRNS 00797 Appendix DTHE SCHOOL BOARD OF POLK COUNTY, FLORIDAMEDICAL TREATMENT AUTHORIZATION FORMTO WHOM IT MAY CONCERN: I the undersigned parent/guardian of ________________________________________ hereby authorize any necessary medical treatment for this student while participating in field trips conducted under the sponsorship of Bartow Medical & Fire Academy ALL HOSA/FPSA Events_ during the 2018 - 2019_school year and guarantee payment of all charges incurred as a result of this medical treatment. INFORMATION: Please Print ALLERGIES TO FOOD, MEDICATION, ETC. (If none, so state.) _______________________ SPECIAL MEDICAL CONDITIONS (If none, so state.)________________________________ FAMILY PHYSICIAN __________________________________________________________ OFFICE ADDRESS ______________________________PHONE NO____________________ PARENT/GUARDIAN NAME____________________________________________________ PARENT/GUARDIAN HOME ADDRESS__________________________________________ HOME PHONE___________________________WORK PHONE________________________ ______________________________ _______________________________________________ Insurance Company Policy No. or Group No. ______________________________________________________________________________ PARENT/GUARDIAN SIGNATURE DATE STATE OF FLORIDA, COUNTY OF ______________________________ I hereby certify that the foregoing was executed before me this ____________ day of_________, by________________________________________, who is personally known to me or who has produced _______________________as identification and who did (did not) take an oath. ____________________________________ Notary Public, State of Florida THIS FORM IS TO BE USED FOR ALL OUT-OF-COUNTY FIELD TRIPS EXCEPT ATHLETIC ACTIVITIES. THE FORM SHOULD BE COMPLETED PRIOR TO THE STUDENT’S FIRST OUT-OF-COUNTY TRIP AND RETAINED ON FILE FOR THE REMAINDERMember profile form HOSA (Fill out if you are in Medical Classes) Please turn in completed member profile and $30 membership dues toAdvisor Hill/Matthews/Hubbard_ in Room Medical classes_ by Sept / 10 /2018____.Name: Grade: Mailing address: Email:Parents names:Home phone: Cell phone:Preferred method of contact [circle all that apply]: email phone mailClass schedule [first semester]:Core Classesperiodclassteacherroom number1234567How did you hear about us? How many years have you been a member?Which of the following interest you? [circle all that apply]:competitive events community service field trips other:conferences leadership opportunities workshopssocial activities chapter meetings fundraisersguest speakers Please list any other extracurricular activities you participate in or offices you hold [you can use the opposite side of form]:Member profile form FPSA (Fill out if you are in Fire Classes) Please turn in completed member profile and $30 membership dues toAdvisor Miles/Huff_______ in Room Fire classes_ by Sept / 10/2017____.Name: Grade: Mailing address: Email:Parents names:Home phone: Cell phone:Preferred method of contact [circle all that apply]: email phone mailClass schedule [first semester]:Core Classesperiodclassteacherroom number1234567How did you hear about us? How many years have you been a member?Which of the following interest you? [circle all that apply]:competitive events community service field trips other:conferences leadership opportunities workshopssocial activities chapter meetings fundraisersguest speakers Please list any other extracurricular activities you participate in or offices you hold [you can use the opposite side of form]: ................
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