Upload
todd-nolt
View
214
Download
2
Embed Size (px)
DESCRIPTION
Leadership Development Program
Citation preview
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, The
Town of Boone, Watauga County 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 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 fundraising activities throughout the year that helps to insure our program can
continue.
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. For weekly
updates and information visit our webpage www.mountainalliance.org or should you
have any questions or concerns please call us at 263-1770, 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, & 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