Shadow Period Preparation Form

Student's Name:

First Name

Last Name

Shadow Period Start Date

YYYY

Shadow Period End Date

YYYY

Current School:

Current Grade in School:

Parent's Name:

First Name

Last Name

Parent's Email:

Phone Number:

(###)

###

####

Additional Phone Number:

(###)

###

####

Does your child have any allergies or medical conditions that we need to be aware of?

Is there anything else you'd like us to know about your child? For example, how is he or she feeling about the shadow day, how to best connect with him or her, etc.?

By signing below, I agree to the following statement:

I will instruct my child (Student), who is attending a Shadow Day at Vine Academy on the date(s) listed above, to follow all instructions and guidelines provided by Vine Academy faculty and staff during his/her shadow day. I hereby release and hold harmless Vine Academy, as well as its respective employees, volunteers, directors, affiliates, and representatives, from any and all liability, damages, and causes of action relating in any way to the Student’s Shadow Day visit to the school. I am unaware of any health issue or restriction that would affect the Student’s participation in the Shadow Day, recess activities, or a fitness class or have outlined them above. In the event of an emergency, I authorize Vine Academy to act for me in its best judgment in rendering any medical attention to the Student. The faculty/staff of Vine Academy is hereby given permission to give basic first aid to my child. I understand that Vine Academy is not to be held liable for the bestowal of such health care. In the event that parents/guardians cannot be contacted, I hereby give my permission for any necessary emergency treatment for the welfare of my child. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.