APHIS Form 120 Native American Summer Application

APHIS 2013 NATIVE AMERICAN
SUMMER PROGRAM
Parental Release Form
I certify that my child,
,who is enrolled with this
agreement, is in excellent health, and may participate in strenuous physical activities associated with the APHIS
Native American Summer Program.
I agree to defend, indemnify, and hold harmless USDA-APHIS and the selected university, its officers,
servants, agents and/or employees, contractors, and insurers from any and all claims for injuries sustained by
my child during his/her participation in this program.
Permission is hereby granted to the U.S. Department of Agriculture and Dinè College to use pictures and
video(s) of my child in any promotional materials.
Permission is granted in the agreement for my child to receive emergency medical treatment, if needed, and I
certify that there are no limits to my child’s participation in the Native American Summer Program activities,
except as stated in writing, and included with the Health History/Emergency Medical Information Form.
I understand and acknowledge that the Native American Summer Program does not offer any medical
insurance to protect against injuries, makes no claims to do so, and has no responsibility for any medical
expenses incurred. I understand that each participant must assume the risk, and any related financial
responsibility that could result from participation in any of these activities. I agree to assume any risk and
financial responsibility.

Parent/Legal Guardian's Signature --

Approved OMB Control No:
0579-XXXX
Expiration Date: xx/xx/xxxx

APHIS FORM 120

Date

According to the Paperwork Reduction Act of 1995, an agency may not
conduct or sponsor, and a person is not required to respond to, a
collection of information unless it dieplays a valid OMB control
number. The valid OMB control number for this collection is
0579- XXXX. The time required to complete this information
collection is estimated to average 2 hours per response, including the
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and
reviewing the collection of information.

APHIS 2013 NATIVE AMERICAN
SUMMER PROGRAM
Health History/Emergency Medical Information Form
Student’s Full Name
(first)

(last)

Birthdate

Age

Address
Parent/Guardian’s Name
Phone/Day

Phone/Evening

Phone/Mobile

Emergency Contact (if parent/guardian cannot be reached)
Name
(first)

(last)

Phone/Day

Phone/Evening

Phone/Mobile

Are any special needs or accommodations required?

Yes

No

If yes, please specify
Are there any activities to be limited by student’s physician?

Yes

No

If yes, please specify
Any allergies?

Yes

No

If yes, please specify
Any prescribed medication being taken?

Yes

No

If yes, please specify
Any food/dietary restrictions?

Yes

No

If yes, please specify
If selected to participate in the Native American Summer Program, you will be required to provide the following
information:
• Copy of Immunization Record from physician or local health department
• Proof of health insurance coverage
I affirm that the information provided above is true to the best of my knowledge. The student herein described above
has permission to engage in all activities relative to the 2013 APHIS Native American Summer Program, except as
noted.

Parent/Legal Guardian's Signature --

Date

APHIS 2013 NATIVE AMERICAN
SUMMER PROGRAM APPLICATION

Student's Full Name
Student's Address

Street
City

State

Zip Code

E-mail Address
Date of Birth
Gender
T-Shirt Size

Male 
Sm 

Female 

Med 

Lge 

X-Lge 

School Name
School Address

XX-Lge 
Grade in
Fall 2012

Street
City

State

Zip Code

Name of Parent/Guardian
Phone/Day

Phone/Evening

Phone/Mobile

If selected to participate in the Native American Summer Program, I promise to abide by the rules and
regulations which govern the program, and to make proper use of the educational advantages offered.
If, for any reason, I violate any part of this contract, I acknowledge I may be dismissed from the Native
American Program, and sent home immediately.
I affirm that the information provided above is true to the best of my knowledge.

Student’s Signature --

Date

Parent/Legal Guardian's Signature --

Date