Coda Intern Application

Coda Intern Application
The following application and parent/guardian consent form is for students serving as volunteer or paid interns at FPK8, OHMS, or VPK8 for Coda afterschool programs. Interns assist Coda staff in music, art, and lego robotics classes, working with 3rd-8th grade students, depending on the location and day.

Free bus rides are available for interns who live in the same school district as the school where they are interning (i.e. students who live in the FPK8 school district can ride home on the bus from FPK8).

Free Meal/Snacks provided.

Interns who are 13 years old or younger will be volunteer only (they cannot legally be paid).

Interns who are 14 or 15 years old must have a work permit in order to be paid.

Please email or call Coda Mountain Academy at info@codamountain.com or (304) 900-0096 with any questions
Intern Applicant's Name*

First NameLast Name
Intern's Date of Birth*

MonthDayYear
Date
Intern's Age*
Intern's Grade*
Intern's Phone Number (optional: for program announcements and information only)
Please enter a valid phone number.

Parent/Guardian 1*

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian 1 Phone Number*
Please enter a valid phone number.
As the parent/guardian, please identify your relationship to the student *
Parent/Guardian 2 (Emergency Contact will be requested later)

First NameLast Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Address*

Street Address

Mailing Address

CityState / Province

Postal / Zip Code

Bus Announcement
Bus Info*

My child will be riding home on the busMy child will NOT be riding home on the bus
Photo Waiver
Understanding that Coda photos and videos are important to promote public awareness, access future scholarship funding and reach more youth, I hereby consent for my child (or myself if 18 or older) to be photographed and/or videoed for Coda Mountain Academy. The resulting photographs or videos may be subsequently used without compensation to me by Coda Mountain Academy, or third parties for publications (including web sites), advertising, Facebook and/or publicity purposes at the discretion of Coda Mountain Academy. Some photos and videos will be used in the year end grant report. I waive the right to inspect or approve the finished photograph, video and/or publication use.*

I, parent/guardian, consent to the above stated photo/video waiver for Coda.I, parent/guardian, DO NOT consent to the above stated photo/video waiver for Coda.
Medical Release
Does Your Child have any Allergies?*

Yes (please explain what Allergies below)No
Food Allergies*
Drug Allergies*
Any medical problems and/or medications that we should be aware of:*
Emergency Contact Person- this is who we will contact if we CANNOT reach Parent/Guardian 1 or Parent/Guardian 2*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship to student*
Parent/Guardian Release Form*

I, the undersigned, am the parent or legal guardian of this minor and have given my consent for him/her to participate in activities hosted by Coda Mountain Academy. In the event of injury, accident, illness or other emergency while participating in the after-school program, I consent to any reasonable medical treatment as deemed necessary by a licensed physician, emergency medical technicians, nurses, and laboratory technicians. In the event any treatment is required, which a physician and/or hospital personnel refuses to administer without my consent, I hereby authorize a Coda associated adult to give such consent for me, if I cannot be reached by telephone at one of the numbers listed above, or because of an emergency in which there is no time or opportunity to make a telephone call. In the event it becomes necessary for that person to give consent for me, I agree to hold such person, other associated adults and Coda Mountain Academy free and harmless of claims, demands, or suits for damages which may arise from the giving of such consent. I also acknowledge that I accept to be ultimately responsible for the cost of any medical care whether or not the cost of that medical care will be reimbursed by my health insurance provider.
Parent/Guardian's Signature*

Clear
Should be Empty:

Coda Intern Application

Experience, Availability & Attendance

Bus Announcement

Photo Waiver

Medical Release