Personal Information Name: ______________________________________________ Date: ____________ Local Address: _____________________________________________________________ ______________________________________________________________ Phone: ________________________ E-mail: ___________________________

Best time/way to reach you: __________________________________________________

Date of Birth: ____________ Notify In Case of Emergency: ______________________________________________ Phone: (______) _____________________ Relationship:___________________ Insurance Company Name: __________________________________________________ Policy Number: ________________________________ Medication(s) taking _____________________________________________________________ Any adverse reactions to drugs/medications? (Penicillin, Aspirin) __________________________

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Allergies? Use an inhaler? (please describe)_________________________

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

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

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

Staff/Volunteer Information/ Medical Form

Experience (Check all that apply and give brief context of experience for each) Mountain Alliance ___________

In What Capacity? ____________________________________________________________________________________________________________________________________________________________ Working with adolescent youth ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What ages? _______________________ Counseling ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Group Facilitation ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Backpacking ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Caving ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Rock Climbing ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ High/Low Ropes ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Biking ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Sailing/Boats: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Multi Media/Web design, photoshop, I movie etc. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Other (please specify) ______________________________________________________________________________________________________________________________________________________

Interests for involvement: Are there specific areas you would like to get more experience/involvement with? Please check the boxes that are of interest. __Alpine Tower/High and Low Ropes __ Biking Program __ Boat Program (on going/every Thursday) __Camping/Backpacking __Caving __Climbing __Community Service __Counseling/Mentoring __ Fundraising/Special Event Planning (Pancakes in the Park, Climbathon) __Group Facilitation __Leadership Initiative for Female Teens __ Membership Meeting Planning Team (Every Other Thursday) __ Multi Media __ Odd Jobs (washing sleeping bags, Gear Shed) __Other:_________________________________ Scheduling/Availability: The majority of our programming occurs after school and weekends: M-F 3:30-7pm. Please indicate time slots that you are available. Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: Current Certifications Expiration Date _______________________________________ ___________ _______________________________________ ___________ _______________________________________ ___________ _______________________________________ ___________ _______________________________________ ___________ _______________________________________ ___________ _______________________________________ ___________ _______________________________________ ___________ Please make copies and attach to this document

References: (please list three)

1.) Name: Relationship: Phone Number: Email:

2.) Name: Relationship: Phone Number: Email:

3.) Name: Relationship: Phone Number: Email: Any other comments/needs/wishes or concerns that we should know about?: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________