Mountain Alliance Instructor Agreement

Respect Guidelines

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

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.

Staff Commitment

I am committed to honoring the Respect & Media Release 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 instructors respect at all times. I have read and understand the above mentioned guidelines, and promise to uphold them at all times. _______________________________________________ ____________ Signature of Instructor Date

Mountain Alliance, Inc. Instructor Medical Form Instructor’s Name _____________________________________________________________________ Emergency Contact:_________________________________Phone(h)_____________(w)_____________ Insurance Company Name __________________________________________________ Policy Number ________________________________ Liability Release

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.

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 or participating 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.

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

Permission to transport and administer care In the event of an emergency in which I must be taken to the hospital for treatment, I hereby give permission to transport me and for hospital staff to begin treatment immediately.

Initial that you have read and understand the above statement: ___ By signing below I am stating that I have read and understand the liability release, acknowledgement of

risk, and permission to transport and administer care paragraphs above. _________________________________________ _______________ Signature of Instructor Date

Instructor Health Information

Instructor’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 instructor a sleepwalker?___________________________ Asthmatic?_________________________ Does instructor have allergies? ….. use an inhaler? (please describe)_____________________________ _____________________________________________________________________________________ Has instructor ever had any previous allergic reaction to bee stings, foods, dust, etc? (Please describe) _____________________________________________________________________________________ _____________________________________________________________________________________ Does instructor have a history of seizures?__________________________________________________ Please list any physical restrictions, previous medical conditions, operations, etc. that might affect participation. __________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Can instructor swim? (CIRCLE ONE) Good Swimmer Can Swim Non Swimmer Does instructor get carsick? ________________________________________ Other factors we should be aware of to care for you: ______________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you have any certifications? (lifeguarding, CPR, first aid, WFR, etc.) Please note when these certifications will expire. _____________________________________________________________________________________ _________________________________________ ____________ Signature of Instructor Date