Dear Students & Parents,

I want to thank you for your interest in Mountain Alliance. The Mountain

Alliance, Inc. is proud to be a collaborative partner working with The United Way and

Watauga County Schools to offer you this exciting and dynamic program. Mountain

Alliance provides its members with an excellent opportunity to meet new friends, become

more involved at Watauga High School and the surrounding community, as well as

develop leadership skills that will last a lifetime. We hope to bring some unique

opportunities to you this year --- some on site at school in the afternoons & evenings, and

others out in our beautiful mountains over the weekends. The Mountain Alliance

mission statement “is to grow leaders through service, adventure, and experience”.

We accomplish this mission by offering team building / group bonding initiatives,

environmental education programs, service-learning activities, and outdoor adventure

expeditions. Our carefully selected staff have all the necessary training and safety

credentials to ensure that each trip goes smoothly and safely. By the way, you don’t have

to know how to do any of these activities, or have any of the equipment, to come out with

us. We’ll provide you with everything you need from gear to instruction. All you need is

to be motivated and committed to taking full advantage of the wonderful opportunity that

awaits you!

This year most of our trips will be heavily subsidized by Mountain Alliance

which means no cost to you. In return we are counting on members to play an active role

in the 2009 Climbathon on Wednesday October 14th

, which will raise money to support

our programs. Also new this year is the Personal Outdoor Discovery Series (PODS).

These outings meet for consecutive weeks and culminate in an all day or sometimes

overnight trip. Once again we will have our open enrollment activities each week that

students can sign up for during our Membership Meetings.

Please take a few minutes to complete the following forms so that we may better

serve you throughout the school year. We can assure you that all the information will

remain confidential and only Mountain Alliance staff will have access to it. Should you

have any questions or concerns please call us at 263-0383, we’ll be more than happy to

talk with you.

Looking forward to many exciting adventures with you!

Todd Nolt

Executive Director

Mountain Alliance, Inc.

Mountain Alliance Leadership Development Program Application

Name ____________________________________________________________________________ Last First Middle Preferred

Address ___________________________________________________________________________

Address City State Zip

Telephone ______________________________ Email __________________________________

Grade ________________ Age _______________ Date of Birth ___________________________

Parents’ Name(s) ___________________________________________________________________

What are your interests? ________________________________________________________

Respect Guidelines

The Mountain Alliance, Inc. strives to create and maintain a positive learning environment that is safe for

every member. We have identified the following items as ‘disrespectful’ & ‘unsafe’ in regards to the well being of

the Mountain Alliance community:

ALCOHOL, NON-PRESCRIPTION DRUGS, TOBACCO PRODUCTS , VIOLENCE/WEAPONS

We have a no-tolerance policy in regards to the above mentioned items. Anyone suspected to be in

violation of these respect guidelines while attending a Mountain Alliance function will result in immediate removal

from the program. In addition, both parents and school officials will be notified upon return from the activity and

tudents will be subject to Watauga County Schools Discipline policy, by Watauga County Schools personnel.

Please do not put us in a position to have to enforce this policy! You have the ability to make the right decision, so

please do so!

Membership Guidelines

Members are encouraged to participate in: 2 Adventure Outings, 2 Service Projects, 1 Fundraiser, &

Membership Meetings each semester. Come talk to me and communicate your scheduling conflicts. Remember,

you will truly only get out as much as you put in!

Media Release

I grant permission to The Mountain Alliance Inc. to use photographs, video, audio recordings, and/or

textual material created by me for use in promotional publications, including web sites or other electronic forms or

media, without notifying me.

Student Commitment

I am committed to honoring the Respect & Membership Guidelines of the Mountain Alliance, Inc. and the

standards of Watauga County Schools. I am also committed to being an active participant in the programs I attend,

to make the best of this opportunity, and to promise my fellow participants and instructor respect at all times.

I have read and understand the above mentioned guidelines, and promise to uphold them at all times.

_______________________________________________ ____________ Signature of Participant Date

_______________________________________________ ____________ Signature of Parent/Legal Guardian Date

Mountain Alliance, Inc. Mountain Alliance, Inc. Parental Consent Form

Participant’s Name _____________________________________________________________________

Parent’s Name(s) ___________________________________Phone(h)_____________(w)_____________

___________________________________Phone(h)_____________(w)_____________

Parent’s Email _________________________________________________________________________

Emergency Contact:_________________________________Phone(h)_____________(w)_____________

Insurance Company Name __________________________________________________

Policy Number ________________________________

Liability Release

As the Parent/Legal Guardian of the above-mentioned participant, I hereby give my consent for

participation in the Mountain Alliance, Inc. program(s). I understand that although all programs will be led by

competent, trained, adult staff & volunteers, utilizing all the necessary safety precautions, there still remains an

inherent risk of injury and/or loss of life resulting from participation in these programs.

Parent or Guardian Initial that you have read and understand the above statement: ___

Acknowledgement of Risk

I assume all risks and hazards incidental to such participation, including transportation to and from the program,

and hereby waive, release, and agree to hold harmless the Mountain Alliance, Inc., its employees, its volunteers,

and any sponsoring agency (including Appalachian State University, its trustees, officers, employees or agents) for

any claims arising out of any loss or injury that the participant might sustain while engaged in this program.

Parent or Guardian Initial that you have read and understand the above statement: ___

Permission to transport and administer care

In the event of an emergency in which my child must be taken to the hospital for treatment, I hereby give

permission to transport my child and for hospital staff to begin treatment immediately.

Parent or Guardian Initial that you have read and understand the above statement: ___

Participation

I give my permission for my child to participate in all after school and half day Mountain Alliance

programming. I understand that weekend and extended outings will require an additional permission slip and parent

or guardian approval. Semester calendars are available at the Mountain Alliance office or on our website

www.mountainalliance.org

Parent or Guardian Initial that you have read and understand the above statement: ___

By signing below I am stating that I have read understand the liability release, acknowledgement of risk,

permission to transport and administer care, and participation paragraphs above. ________________________________________ _______________ Signature of Parent/Legal Guardian Date

_________________________________________ _______________ Signature of Participant Date

Participant Health Information

Participant’s Name ___________________________________________________________

Birth date ____________________________________ Height_______________ Weight ____________

Date of last Tetanus Booster Immunization ________________________________________

Medication(s) taking _____________________________________________________________________

Dosage(s)__________________________Time to be administered_________________________

Any adverse reactions to drugs/medications? (Penicillin? Aspirin?)_________________________________

______________________________________________________________________________________

Is participant a sleepwalker?___________________________ Asthmatic?_________________________

Does participant have allergies? ….. use an inhaler? (please describe)_____________________________

_____________________________________________________________________________________

Has participant ever had any previous allergic reaction to bee stings, foods, dust, etc? (Please describe)

_____________________________________________________________________________________

_____________________________________________________________________________________

Does participant have a history of seizures?__________________________________________________

Has participant ever slept away from home?_________________________________________________

Please list any physical restrictions, previous medical conditions, operations, etc. that might affect

participation. __________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Can participant swim? (CIRCLE ONE) Good Swimmer Can Swim Non Swimmer

Does participant get carsick? ________________________________________

Other factors we should be aware of to care for your child: ______________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_________________________________________ ____________ Signature of Parent/Legal Guardian Date