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JAWM BEE Student Application






JA BEE STUDENT RECOMMENDATION

Thank you for your student recommendation! Please explain why you feel this student would
benefit from and why they deserve to be part of our summer program.

Thank you for your interest in the JAWM BEE Summer Program. Please fill out the following information. Student applications can be mailed to 1500 Main Street, Suite 217 / PO Box 15167, Springfield, MA 01115, emailed to Megan Beliveau at mbeliveau@jawm.org, or faxed to (413) 747-7606.

Gender
MaleFemale

Student t-shirt size
SMLXL2XL

Will the student need a PVTA Bus Pass?
YesNo

The BEE Summer Program is four weeks long. If the student will be attending for all four weeks, please check all four weeks. If the student will not be attending all four weeks, please check the weeks the student will be attending:
July 8-12July 15-19July 22-26July 29-August 2

The normal summer program hours are Monday-Friday, 9am-3:30pm. Breakfast is served 8:30am-9am and lunch is served 12:00pm-12:30pm. Extended hours are offered 7:45am-9am and 3:30pm-5pm. Will the student be utilizing the extended hours every day or some days? Please explain:

List of people who are authorized to drop off or pick up the student:

Person #1
Name

Relationship

Phone #

Person #2
Name

Relationship

Phone #

Person #3
Name

Relationship

Phone #

Person #4
Name

Relationship

Phone #

Person #5
Name

Relationship

Phone #


ALLERGY FORM – **Please only fill out below if the student has an allergy we need to be aware of.

Do you think your child’s food allergy may be life-threatening?
YesNo

Did your student’s health care provider tell you the food allergy may be life-threatening?
YesNo

History and Current Status:
Check the foods that have caused an allergic reaction:
PeanutsPeanuts or nut butterPeanut or nut oilFish/shellfishEggsSoy productsMilkTree nuts (walnuts, almonds, pecans, etc.

Please list any other allergies:

How many times has your student had a reaction?
NeverOnceMore than once, explain below

When was the last reaction?

Are the food allergy reactions:
Staying the sameGetting worseGetting better

TRIGGERS AND SYMPTOMS:
What has to happen for your student to react to the problem food(s)? (Check all that apply)
Eating foodsTouching foodsSmelling foodsOther, please explain below

What are the signs and symptoms of your student’s allergic reaction? (Be specific; include things the student might say.)

How quickly do the signs and symptoms appear after exposure to the food(s)?
SecondsMinutesHoursDays

TREATMENT:
Has your student ever needed treatment at a clinic or the hospital for an allergic reaction?
NoYes, please explain below

Does your student understand how to avoid foods that cause allergic reactions?
YesNo

What treatment or medication has your health care provider recommended for use in an allergic reaction?

Has the student used the treatment?
YesNo

Does your student know how to use the treatment?
YesNo

Please describe any side effects or problems your child had in using the suggested treatment:

If medication is needed at the summer program, have you brought the medication/treatment supplies to the summer program?
YesNo, I need to get the medication/treatment and bring it to Junior Achievement

What do you want us to do at our summer program to help your student avoid problem foods?

I give consent to share, with other students, that my child has a life-threatening food allergy.
YesNo