STATE OF MISSISSIPPI
GOVERNOR’S PAGE PROGRAM
APPLICATION FORM FOR PAGES
(Please Print)
NAME ______
HOME ADDRESS______
CITY______STATE ______ZIP CODE______
DATE OF BIRTH ______AGE ______
HOME TELEPHONE NUMBER (_____) ______
CELL PHONE (_____)______
ANY MEDICAL, ALLERGIES, OR SPECIAL NEEDS______
Week Desired: 1st Choice: ______
*Choose 1 week from
January 5, 2016 through
April 8, 2016 2nd Choice: ______
Have you previously served as a Governor’s Page? ______When? ______
School Activities /Interests: ______
______
Local newspaper name and e-mail address: ______
______
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PARENTS/LEGAL GUARDIAN
ADDRESS______
CITY______STATE______ZIP CODE______
TELEPHONE NUMBERS (HOME) ______WORK (_____)______
PERSON TO CONTACT IN CASE OF EMERGENCY______
TELEPHONE NUMBER(S)______
RELATIONSHIP TO PAGE______
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(IF REQUIRED BY SCHOOL)
PRINCIPAL’S SIGNATURE______
NAME OF SCHOOL______
LIABILITY WAIVER AND INSURANCE STATEMENT
I acknowledge my minor child’s participation in the State of Mississippi Governor’s Page Program.
I understand that participation in this program involves potential risks, including the possibility of injury, death, or property loss due to negligence or other causes, and I have explained these things to my child.
In consideration for being allowed to participate in the program and use the facilities and services provided by the State, I agree to assume responsibility for all risks my child may incur.
I hereby agree to indemnify and hold harmless the State of Mississippi, its officers, employees, agents and volunteers, from any and all negligence, claims and causes of actions, damage, and liability arising from or related to my child’s participation in the program specified above.
I further certify that my child is covered by a comprehensive medical insurance policy that will be in effect during the dates of the program specified above.
I understand that I must make provision before my child’s arrival in Jackson for continuation of medical treatments such as prescriptions and special diets.
PARENT/GUARDIAN DATE
RECOMMENDATIONS
Signed statement of supports may be provided in the space below or attached separately.
1. SCHOOL REFERENCE (i.e. School Counselor, Teacher, Principal, etc.)
______ (signature)
2. COMMUNITY REFERENCE (i.e. Clergyman, Employer, Relative, etc.)
______(signature)
PLEASE RETURN COMPLETED APPLICATION BY MAIL, FAX, OR EMAIL:
Governor’s Office
Attn: Debbie Carney ()
P.O. Box 139
Jackson, MS 39205-0139
601-576-2028 - phone
601-359-3741 - fax