Dear Magruder Parents and Guardians,

Every 15 Minutes is a national program designed to help high school juniors and seniors realize the unnecessary
tragedies that can result from unsafe decisions made when driving. The official website is
http://every15minutes.com.

The program is named after the statistic when it began in the 1990’s, that someone in the United States died
every 15 minutes from an alcohol-related accident. The statistic is now almost every 40 minutes, so it does
reach a significant number of teenage drivers.

This two-day program will be at Magruder HS March 17th and 18th. All Juniors and Seniors may apply to be one
of (approximately) forty “living dead” students, which means they will either be pulled out of class, one every
15 minutes, by the Grim Reaper throughout the school day, or they can take the role of a victim or the drunk
driver in a simulated rescue scene, with actual emergency and police vehicles responding.

These students will have make-up applied to appear dead and then return to class for the remainder of the day.
After school, they will go to Pumphrey Funeral Home and then an overnight retreat to listen to speakers and
write a letter to their family about how their participation has affected them.

Students who want to participate must submit the attached Parent/Guardian Permission Form and the Student
Application Form NO LATER THAN DECEMBER 16, 2010.

If you have questions or want more information, please contact Patty Winters, PTSA Every 15 Minutes
Program Coordinator, at 301-519-7537 or patty.winters@verizon.net.
 PARENT/GUARDIAN PERMISSION FORM
MAGRUDER HIGH SCHOOL
THURSDAY, MARCH 17TH to FRIDAY, MARCH 18TH, 2011

HARD COPIES ONLY PLEASE!!

*Please read all sections carefully before signing*

SUBMISSION DEADLINE: THURSDAY, DECEMBER 16, 2010.

If your teen is selected to participate as a “living dead” student (pulled out of class by the Grim Reaper) or a
simulated rescue scene participant, a parent/guardian must attend a mandatory pre-program information
meeting (date to be announced) to review details of your teen’s participation.

As part of this application process, you are asked to write a mock obituary about your teen (unless he/she is the driver or
injured passenger in the simulated rescue scene), which will be read to your teen’s class by a Police Officer. All
obituaries will be posted on a board in a common area for the Magruder High School community to see. (See sample
obituary at the end of this form.)

Please attach a recent photo of your teen and a typed copy of your teen’s obituary along with your completed application,
and deliver it to the PTSA mailbox in the Main Office in an envelope addressed to Patty Winters. If you need assistance
with writing or typing your teen’s obituary, please contact Patty Winters at 301-519-7537.

Student_____________________________________________Grade_____Date____________
First Name Middle Initial Last Name

Student E-mail Address and Cell Number: ___________________________________________

Parent/Guardian Name and Address: ________________________________________________

Parent/Guardian E-mail Address: ___________________________________________________

Parent/Guardian Phone #s ______________________(H) ___________________________(W)

_______________________(Cell) _________________ (Alternate)

Emergency Contact #1___________________________________________________________

Relationship _______________________________Phone # _____________________________

Emergency Contact #2 ___________________________________________________________

Relationship________________________________Phone#______________________________

PARENT/GUARDIAN CONSENTS

Please initial each item to which you agree:

_____ I give my consent for my teen to ride on an MCPS school or charter bus. Students will depart Magruder High
School at 3:30 p.m. on March 17th 2011 for Pumphrey’s Funeral Home, 300 West Montgomery Ave. in
Rockville. From there, students will be transported to the overnight retreat site.

The retreat location will be discussed at the mandatory Parent/Guardian Information Meeting referenced above.
In the past, other students have “crashed” the retreat and brought alcohol, so we ask you to please understand
and respect the confidentiality of the location.

_____ I agree to not have any contact with my teen from the time he/she leaves home for school on March 17th, until
after the assembly on March 18th unless there is a true family emergency. As my teen will not have his/her cell
phone during this time, I understand I can reach him/her through an Every Fifteen Minutes volunteer or chaperone,
whose cell numbers will be provided to me prior to their departure for the retreat site.

Please note that on their application form, students agree to leave their cell phone home when they leave for
school March 17, or turn it in to Security when they arrive at school. Students who turn phones in at school will
have them returned during the Appreciation Brunch.

_____ I will not come to the school grounds to witness the staged accident. This can be a distraction for the students.

_____ I give permission for my teen to attend the mandatory overnight retreat. Students will have to miss work and
afternoon/evening sporting events on Thursday, March 17th 2011, as well as make up any missed
homework/schoolwork.

VIDEO PARTICIPATION/MEDIA RELEASE

We will produce a student video to record highlights of the Every Fifteen Minutes Program, including what led to the
crash, participants at the scene just after the crash, etc. In producing this video, scenes might be recorded that include
your teen. This video will be shown to Magruder High School students during the assembly on March 18th, and possibly
other events such as an information table at Back to School Night or fund-raising presentations to civic groups. The
video will clearly indicate that it is a simulated event.

Please initial each item to which you agree:

_____ I agree that my student may be shown in this video.

_____ I consent to the use of the Every Fifteen Minutes Program highlights video at the March 18th assembly, and
possibly at other educational settings at Magruder High School.

_____ My teen has my permission to be interviewed, to help capture his/her thoughts and feelings about the
“Every Fifteen Minutes” program. This interview could be made part of a school news article or video for educational
purposes.

_____ My teen may be interviewed and taped by the local news media.

SPECIAL CONCERNS

Medications
Is your teen currently taking any medications? Yes ______ No_______ If yes, are there any special accommodations we
should make or anything we should know about the medication regarding the overnight retreat? Explain
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________
Dietary Restrictions
Does your child have any dietary restrictions? Yes ______ No _______
If yes, please list _______________________________________________________________
_____________________________________________________________________________

Individuals with Disabilities

Individuals with disabilities are encouraged to apply and participate in the Every 15 Minutes Program. To
adequately plan for a successful and rewarding experience, please contact Ms. Jennifer Reynolds Every Fifteen
Minutes Committee Faculty Co-Chair, at (301) 840-4600 NO LATER THAN FEBRUARY 4th, 2011.

Is there anything else we should know, so that we can make special accommodations for your teen during the two days of
the program? ___________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

OPTIONAL MOCK ARREST/INJURY/DEATH NOTIFICATION

As part of this educational activity, the parent/guardian of each student participant can choose to receive a mock
arrest/injury/death notification/visit from the Police Department. The officer visiting your home or worksite will identify
him/herself as being from the Magruder High School Every Fifteen Minutes Program, and will proceed with standard
Montgomery County Police protocol when authentic notifications of an arrest, injury, or death are made.

(Please note that notifications are made by visit only, no phone calls, as in the case of an actual notification.)

Please initial below:

_____ I do not want to receive a mock arrest/injury/death notification visit.

_____I would like to receive a mock arrest/injury/death notification visit.

Please provide the following information if you have elected to receive the mock arrest/injury/death notification:

Address where notification will take place between 7 AM. and 5 P.M.:

____________________________________________________________________________

Is this a home or work address? _____________________

PARENT/GUARDIAN CONSENT FOR TEEN TO PLAY THE ROLE OF A CRASH VICTIM WHO DIES IN
THE EMERGENCY ROOM (To participate in this phase of the event, parents/guardians must consent to the items
below.)

____Yes ____ No I give permission for my teen to be transported via ambulance to Shady Grove Adventist
Hospital on March 17th 2011 and to be brought back to school by a program volunteer.

____Yes ____ No I am willing to go in person to the hospital and role-play in a scene in

which the Emergency Department doctor explains that the staff trying to save my teen
was unsuccessful.
INVITATION TO ASSEMBLY AND APPRECIATION BRUNCH (March 18th)

We hope you can attend both the assembly and brunch to celebrate your teen’s courage and growth.

Assembly: 8:15 a.m. – 9:55 a.m. (Auditorium)* .

Brunch: 10:05 a.m. – 11:30 a.m. (Media Center)*
*These times are subject to change between now and the event date. We will keep you informed of any modifications in
the schedule.

Number of parents/guardians attending the assembly _______

Number of parents/guardians attending a brunch following the assembly _______

Parent/Guardian Signature ______________________________ Date____________________

Questions? Please contact Patty Winters, Every 15 Minutes Program Coordinator, at patty.winters@verizon.net or 301-
519-75378.

SAMPLE OBITUARY

Sifredo Zavala, cherished son of Maria and Angel Zavala, of Rockville, MD, passed on Friday, March 17, 2011,
as the result of injuries from an auto collision.

Sifredo, a senior at Magruder High School in Rockville, MD was an aspiring young artist who enjoyed
spending time with family and friends, listening to music, and studying information regarding gang prevention.
Sifredo was employed as a student intern at the Rockville City Police Department and was looking forward to
graduating and going on to college. Sifredo planned to become involved in criminal investigations.

Friends and relatives will be received by the family at Pumphrey’s Funeral Home in Rockville on Monday,
March 21, 2011, between the hours of 3:00 p.m. and 6:00 p.m. Funeral services will be held at the St.
Catherine’s Catholic Church on Tuesday, March 22, 2011, at 11:00 a.m.

It would be Sifredo’s wish that, in lieu of flowers, contributions be made to either La Casa de Maryland or El
Centro Martinez para los Jovenes.

Sifredo is survived and missed by his mother and father, sisters Angela and Mercedes Zavala, grandfather
Rafael Lopez and grandmother Rosa Lopez.
 STUDENT APPLICATION
MAGRUDER HIGH SCHOOL
THURSDAY, MARCH 17th to FRIDAY, MARCH 18, 2011
*Please read all sections carefully before signing*

PLEASE RETURN APPLICATION TO THE PTSA MAILBOX IN AN ENVELOPE ADDRESSED TO

MRS. WINTERS BY THURSDAY, DECEMBER 16, 2010 WITH COMPLETED PARENT/GUARDIAN
PERMISSION FORM.

NO ACTING SKILLS ARE REQUIRED. ALL juniors and seniors are encouraged to apply. ACADEMIC
ELIGIBILITY IS NOT REQUIRED FOR PARTICIPATION IN EVERY 15 MINUTES. The number
of students accepted is contingent on the number of chaperones available for safe supervision.
All participating students will be excused from class for the time it takes to have makeup applied to identify
their role as a “living dead” student or simulated crash victim. Accident participants will be excused for 6th
and 7th periods, to be able to have lunch after the accident.

Student_____________________________________________Grade_____Date____________
First Name Middle Initial Last Name

Student E-mail Address and Cell Number: ___________________________________________

Student T-Shirt Size (Adult sizes): ____S ____M ____L ____XL ____XXL

STUDENT INITIALS REQUIRED:

_____ I understand that I am expected to attend classes when I am not directly involved in activities
pertaining to the Every Fifteen Minutes Program and that I will be responsible for any missed work.

_____ I agree to leave my cell phone at home or turn in my cell phone to Magruder Administration or
Security when I arrive at school on March 17th. It will be returned to me at the appreciation brunch on
March 18th.

_____ I understand that I will not have any contact with my family from the time I leave for school on
March 17th until after the Assembly on March 18th, unless there is a true family emergency. (If you
drive to school, please make other transportation arrangements so your car is not left in the student lot
overnight.)

_____ If I am selected to be a “Living Dead”, I agree to not speak to anyone once the Grim Reaper calls
my name, for the entire school day on March 17th, unless it is absolutely necessary.

_____ If I am selected for another role, such as an injured passenger or the drunk driver, I will do my best to
act in that role throughout the school day on March 17th.
_____ I understand that if anyone verbally or physically abuses me during my Every 15 Minutes role-play, I
may step out of my role to seek assistance from any Magruder staff person or an Every Fifteen Minutes
adult volunteer wearing a white Every Fifteen Minutes T-shirt.

_____ I understand that whatever role I am assigned, the success of Every Fifteen Minutes depends on
my taking my responsibilities as a participant seriously.

I have read all of the above material and grant permission for all of the agreed upon items above.

Student Signature ___________________________________ Date____________________

Parent/Guardian Signature __________________________ Date____________________

TO THE STUDENT: On a separate paper attached to this form, please explain why you would like to be a
part of the Every Fifteen Minutes Program. Please type your statement to avoid confusion or delay the
selection process.
In your statement, please indicate the role that you would like to play during the program and explain the
reasons for your selection. We will do our best to honor your preference; however, we might need to assign you
to a different role.

Place a “1” by your first choice and a “2” by your second choice:
___ A “Living Dead” Student (pulled out of class by the Grim Reaper)
___ Staged crash victim with minor injuries
___ Staged crash victim with fatal injuries (dead on the scene; you must remain silent and motionless during
the entire simulated rescue)
___ Staged crash victim who will be transported to Shady Grove Adventist Hospital Emergency Room
(victim will “die” there; parents/guardians must consent to participate in scene in which the doctor
explains to them you died as the result of a collision)
___ Student arrested and taken to the police station for DUI (Driving Under the Influence)

Questions? Please contact Mrs. Winters, Every 15 Minutes Program Coordinator, at

patty.winters@verizon.net, or 301-519-7537. Thank you for applying!!!!