Medical Health

Location:

Portsmouth, VA

Salary:

Anything

Posted:

March 10, 2021

Contact this candidate

Resume:

Parental Affirmation

I, Kendra Scott, Parent/Guardian, under penalty of perjury, do hereby affirm to the Ice4Life Foundation, Incorporated, that I authorize the participation of Jamiyah Brewer, (“Participant Minor Child”, in the Perfectly P.R.E.T.T.Y. mentorship program (including planned activities), and that I have the legal authority to provide my consent and authorization for such participation.

Printed Name: Kendra Scott

Signature: Kendra Scott

Date:_06/17/2020

Relationship to Child: Mother

Waiver and Release

I, Kendra Scott, Parent/Guardian, on behalf of Jamiyah Brewer (“Participant Minor Child”) do hereby release, waive, discharge, covenant not to sue and agree to hold harmless the Ice4Life Foundation, Incorporated, it’s officers, Board of Directors, members, employees (collectively, “ Releasees”), from any and all claims, demands and actions of any every kind directly arising out of, or relating in an respect to Participant Minor Child’s participation in the Perfectly P.R.E.T.T.Y. program.

My waiver and release of all claims, demands, actions, and liability shall include without limitation, any injury, illness, death, property damage, or loss to the Participant Minor Child which may be caused by any act, or failure to act, by the Releasees, unless such injury, illness, death, property damage or loss is a direct result of the willful misconduct of the Releasee.

I understand that, without limitation of the foregoing, neither the Ice4Life Foundation, nor the program, shall be liable and each is hereby released from all claims that may arise from loss or damage to the Participant Minor Child’s personal property.

Kendra Scott

Parent/Guardian Signature

06/17/2020

Date

Code of Conduct for Youth

Participating in Perfectly P.R.E.T.T.Y. Mentorship Program

1.Respect all participants (other youths and adult volunteers) by not using foul, hurtful, or obscene language or engaging in physical violence, or other aggressive behaviors that threaten the safety of others. Do not bring weapons, cigarettes, drugs/alcohol, or anything illegal to any activity at any time.

2.There is zero tolerance for bullying (including cyber bullying) in our program. Any participant found guilty of bullying will be removed from the program immediately.

3.Do not use Ice4Life Foundation and/or Perfectly P.R.E.T.T.Y.’s name and/ or logo on any clothing, book bags, or other items that are not approved by the Ice 4Life Foundation.

4.Stay within the program’s designated areas within the building or out on field trips.

5.Assume full responsibility for all personal belongings. Please leave valuables at home.

6.All participants are required to actively participate in all program activities. Participants will be allowed two excused absences at the discretion of the Board. Any participant who has more than 2 unexcused absences will be removed from the program.

7.Parents are responsible for providing the Board with accurate contact information to include phone number and an email address. It is also the parent’s responsibility to inform the Board if you are not receiving correspondence.

8.Parents are responsible for dropping off and picking up participants by the established start and end time for the activity. It is the responsibility of the parent to advise a Board member when the participant is going to be late.

9.Participants are not permitted to bring guests to program activities unless it is a fundraiser or has been pre-approved by a Board Member.

10.Participants are required to submit grades during each grading period.

11.Participants must adhere to the established dress code for each program activity.

Sanctions for Violating Code of Conduct

Bad Language/Bullying/Physical Violence and other Misconduct:

***Any participant found guilty of Bullying will be immediately removed from the program

***Illegal Substance: Youth is removed from the program. If a youth is in possession of an illegal substance or dangerous weapon the police will be notified as well.

1st Time: Verbal warning, parent or guardian notified from this point forward

2nd Time: Removed from the program

Next occurrence, youth is removed from program

With my parent, I have read the Code of Conduct and sanctions for violating the Code. I understand the Code and the sanctions. I will follow the Code of Conduct.

_Jamiyah Brewer Jamiyah Brewer

Print Name Signature Date 06/17/2020

I have read and understand the Code of Conduct and sanctions for violating the code of Conduct. I understand that my child’s compliance with the Code of Conduct is a condition of her participation in the Perfectly P.R.E.T.T.Y. program. I agree that the sanctions for violating the Code of Conduct are reasonable and will help my child comply.

_Kendra Scott Kendra Scott

Parent Name Parent Signature Date 06/17/2020

Medical Information Form

Today’s Date: 06/17/2020

Health History:

Child’s Name (Last, First, M.I.) Brewer, Jamiyah, A.

Gender (check one): Female DOB (mm.dd.yyyy) 02/14/2006

Parent/Guardian Name: Kendra Scott

Does Parent/Guardian live at home w/ the child? Yes

Parent/Guardian Name:

Does Parent/Guardian live at home w/the child?

Is/Has the child been under regular supervision of a physician? Yes

Name and address of physician Jennifer McMurray

Date of last physical exam 10/30/2019

Health and Developmental History:

Childhood illness: Check all that apply

Measles Asthma Chickenpox Rheumatic Fever Hay Fever Diabetes Epilepsy Whooping Cough Poliomyelitis

Ten-Day Measles(Rubella) Three Day Measles (Rubella

Other (please list)

Does child have any significant health history, conditions, communicable illness, or restrictions that may affect the child’s participation in the Perfectly P.R.E.T.T.Y. programs? No

If yes, please provide detailed explanation

Does child have any significant food/medication/environmental allergies that may require emergency medical care during the Perfectly P.R.E.T.T.Y. program? No

If yes, please provide detailed explanation

Specify any other serious or severe illness or accidents:

Does child take prescribed medications:. No

over-the-counter medications? No

If yes, name of medications

Frequency taken

(For any medications or treatment required during the course of the Perfectly P.R.E.T.T.Y. program, A MEDICATION Authorization form should be completed and submitted with this form)

Does child have allergies? Yes If yes, please specify Seasonal

Does the student use any special devices? (hearing aids, cochlear implants, etc? name of device reason for use

Emergency Medical Treatment Authorization Form

Name of Minor: Jamiyah Brewer

Date of Birth: 02/14/2006 Age: 14

Address: 709 Bismarck Myrick St

City/State/Zip Portsmouth, VA 23704

Parent/Guardian Home Phone: 757-***-****

Cell Phone 757-***-**** E-mail address: ************@*****.***

Minor’s Fender Female Height Weight

Health Information

Below, please check any current health condition that may require attention during the Program day. Also please complete and submit the Medical Authorization Form if tour child has health conditions that require medications during the Program day.

Allergies (be specific)

Foods Medicines Bee stings/insect bites other

Asthma inhaler required at Program?

Vision problems glasses contacts

Hearing problems hearing aids

ADD/ADHD

other

List all medications and dosages your child receives on a continual basis

Emergency Contact Form

Parent/Guardian #1

Name Kendra Scott

relationship Mother

Address 709 Bismarck Myrick St City Portsmouth State VA Zip 23704

Home phone 757-***-**** work phone 757-***-**** x 8307 cell phone 757-***-****

E-mail address ************@*****.***

Parent/Guardian #2

Name Artamus Flythe

relationship Father

Address City State Zip

Home phone work phone cell phone 757-***-****

E-mail address

If for any reason I/We cannot be reached, please contact the following person(s) whom I/We hereby authorize to seek emergency medical or surgical care for my/our child.

Name Nokia Rollins

relationship to student cousin

Address 1401 Lake Forest Dr City Portsmouth State VA Zip23701

Home phone 757-***-**** work phone cell phone

E-mail address **************@***.***

Name Franita Delk

relationship to student Aunt

Address 1401 Lake Forest Dr City Portsmouth State VA Zip 23701

Home phone 757-550- 7817 work phone cell phone

E-mail address

Parent/Guardian Signature Kendra Scott

Date 06/17/2020

Parent/Guardian Signature Date

General Field Trip Permission Form

I/We, Kendra Scott, (“Parent/Guardian”), as parent(s) or legal guardian(s) of Jamiyah Brewer__(“Minor Child Participant”), give permission for my/our child to participate in Perfectly P.R.E.T.T.Y. programs activities taking place off site. I/we understand that transportation to and from these activities will be provided by me as the parent/guardian, unless otherwise stated at least 48 hours in advance that the Ice4Life Foundation, Inc. will be providing transportation.

I/We understand that the field trips are part of the Perfectly P.R.E.T.T.Y. program, and if I/we choose not to have my/our child participate in one or more off-site activities, I/we must make other care arrangements for my/our child during the times of that field trip activity, if it is on the day of a regularly-scheduled meeting.

I/We assume all risks and hazards of loss or injury of any kind that may arise in connection with such trips, except those arising from gross negligence or intentional infliction of harm by the program, its offices, agents, or employees.

I/We do hereby agree to release and hold harmless the Ice4Life Foundation, Inc, its officers, Board of Directors, members, employees, agents, representatives, and assigns from any and all claims, costs, suits, actions, judgments, and expenses for any damage, loss, or injury to my/our child or damage to my/our child’s property arising from my/our child’s participation in field trips, other than damage, loss, or injury that results from gross negligence or intentional infliction of harm by the Ice4Life Foundation, its offices, Board of Directors, members, employees, representatives, agents, and assigns.

Parent/Guardian Signature Kendra Scott Date 06/17/2020

Kendra Scott

Print Name

Parent/Guardian Signature Date

Print Name

Youth acknowledgment and Signature:

I, Jamiyah Brewer, understand the code of conduct is to be enacted on any field trips with the Perfectly P.R.E.T.T.Y mentoring program. I am responsible enough to follow the Code of Conduct and promise to do so on all off-site activities.

Jamiyah Brewer Jamiyah Brewer

Print Name Signature Date 06/17/2020

Youth Pick – Up Authorization Form

I authorize the persons listed below to pick up my child from the Perfectly P.R.E.T.T.Y. program. For my child’s safety, I understand that all authorized persons on the list below will be asked to show photo identification before my child will be released to them: therefore, I will notify all authorized persons of the requirement so that they will have photo identification with them when they arrive to pick up my child. (Please include names of either parents or guardians on the list below)

Name Vernon Scott

Relationship Step-father

Phone 757-***-****

Alternate phone

Name Anthony Bowden

Relationship Uncle

Phone 757-***-****

Alternate phone

Name Cynthia Hudson

Relationship Grandma

Phone 757-***-****

Alternate phone

Name Tinisha Flythe

Relationship Step-mom

Phone 757-***-****

Alternate phone

Name Stephanie Copeland- Rodriguez

Relationship Grandma

Phone 757-***-****

Alternate phone

By signing below, I verify that I have read and agree to the Student Pick Up policies described above and authorize the Ice4Life Foundation to release my child to the persons listed above. I also agree to notify the Ice4Life Foundation in writing of any changes to the above list of authorized persons.

Mother/Guardian Signature Kendra Scott Date 06/17/2020

Father/Guardian Signature Date

PHOTOGRAPH AND VIDEO AUTHORIZATION AND RELEASE FORM

I/We, Kendra Scott_, (“Parent/Guardian”), as parents(s) or legal guardian(s) of _Jamiyah Brewer, give permission for the Ice 4 Life Foundation, Incorporated, to publish on the internet or medial still photographs or moving images, including if applicable, any sound recordings accompanying the images (“Images”) taken of my child at Perfectly P.R.E.T.T.Y. mentoring programs without payment or any consideration and without notifying me.

I/We understand and agree that the images will become the property of the Ice4Life Foundation, which shall have complete ownership of the images. I hereby irrevocably authorize the Ice4Life Foundation, Inc. and any partner of Ice4Lifeto publish or distribute these Images. I hereby irrevocably authorize the Ice4Life Foundation, Inc. to publish or distribute these images for the purpose of publicizing the Perfectly P.R.E.T.T.Y. program or any other lawful purpose. In addition, I waive any rights to royalties or other compensation arising out of or related to the use of the Images.

I/We hereby hold harmless and release and forever discharge the Ice4Life Foundation and any of its officers, Board of Directors, members, employees, representatives, agents and assigns from any and all claims, costs, suit, actions, judgments, and expenses which my child, his/her heirs, representatives, executors, administrators, or any other persons acting on his/her behalf have or may have by reason of the use of the images. This release specifically includes, without limitation, a complete release and discharge of any liability by virtue of any editing, distortion, alteration, or optical illusion, whether intentional or otherwise, that may occur or be produced in the taking of or editing of said Images, unless it can be shown the such was maliciously cased, produced and published solely for the purpose of subjecting my child to conspicuous ridicule, scandal. reproach, scorn and indignity.

I/We hereby certify that I/We are the parents of _Jamiyah Brewer, and do hereby give my/our consent without reservation to the foregoing on behalf of my/our child.