Junior Leader Application | PC Afterschool Hula

VOLUNTEER JUNIOR LEADER APPLICATION FORM

VOLUNTEER INFORMATION

Student Last Name

Student First Name

Recommending Teacher

Select if applicable. I am:

the older sibling of a PCHES student

Experience with children:

Yes, some (babysitting, etc.)

None, this will be a first

We will iron out frequency & start/end times around your club/sport/parent schedules (e.g. one Tues a month from 3-4 pm). Your homework/tests/projects are your priority so don't ever worry about changing your schedule at any time. Same if you just need or want to take a break. Just be sure to let us know you won't be coming so we don't worry (because we will).

Description of volunteer hours: Junior Leaders will assist with K-6 students doing homework, doing arts & crafts and other quiet time activities, playing indoor/outdoor games/sports, and learning hula/oli. Throughout their interactions with students, Junior Leaders will be a good role model and set a positive example at all times while gaining various hands-on learning experiences detailed on the "Goals During Volunteering" sheet.

PARENT/GUARDIAN INFORMATION

Parent/Guardian Last Name

Email

Parent/Guardian Last Name

Email

Parent/Guardian First Name

Primary Phone #

Secondary Phone #

Parent/Guardian First Name

Primary Phone #

Secondary Phone #

EMERGENCY CONTACT INFORMATION

NAME

PHONE

NAME

PHONE

PEDIATRICIAN'S NAME

PHONE

Pediatricians will only be contacted for medical decisions if parents/guardians cannot be reached.

I give my consent for appropriate action to be taken for my child's well-being.

I understand I am financially resposible for ambulance transport and hospital charges incurred on my child's behalf in a warranted medical emergency.

ALLERGIES / MEDICATIONS / MEDICAL CONDITIONS

WAIVER, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT

I understand that photographs/videos may be taken during after school activities and hereby grant the program permission to use any such photo(s)/video(s) online, and in any print materials or presentations.

I understand that my child's participation as a volunteer junior leader in the after school activities offered by Pearl City Afterschool Hula, LLC is not without known and unknown risks.

I understand that Pearl City Afterschool Hula, LLC is in full compliance with all school and state liability insurance requirements, and that they have provided the school with their Certificate(s) of Insurance per state regulations and further understand that my child's coverage under Pearl City Afterschool Hula LLC's liability insurance does not include any punitive damages for gross negligence claims.

I understand that the State of Hawaii and Department of Education requires liability waivers and indemnification agreements from the participants of Pearl City Afterschool Hula, LLC's after school activities that take place on Pearl City Highlands Elementary School grounds, as applied to all instances of my child's participation in said activities, as well as any related off-campus measures that may be taken in regard to my child's safety or well-being.

Indemnification Statement: The undersigned individual(s), heirs, personal representatives, agents, and successors, for and in consideration of the State of Hawaii Department of Education permitting and allowing the use of the designated school rooms, buildings, and/or facilities jointly and severally agree(s) to indemnify and save harmless the State of Hawaii Department of Education and Pearl City Afterschool Hula, LLC, against any and all loss, liability, demands, claims, suits, action or proceedings of every name, character and description which may be incurred by or brought against the State of Hawaii Department of Education and/or Pearl City Afterschool Hula, LLC for or an account of any injuries or damages to any person or property received or sustained by any person, directly or indirectly, by or in consequence of the participation of said activities and use of the school facilities/grounds.

Electronic Signature (type your first and last name)

I am the child's parent/guardian, authorized to acknowledge and accept all terms on this form.

Acceptance and Acknowledgement

By checking this box, I hereby certify my typed electronic signature and consent that my child participate as a volunteer junior leader, asserting my full understanding and agreement to the above statements, and executing the above agreement, waiver, and release on his/her behalf.