Take a Hike - WordPress.com€¦ · Take a Hike is a full-time, alternate high school program for youth who were formerly disengaged. Embedded in the public school system, the program

PROGRAM APPLICATION

1 | P a g e TAH Application Package © 2018 Take a Hike Foundation

Take a Hike is a full-time, alternate high school program for youth who were formerly disengaged.

Embedded in the public school system, the program is offered in partnership with the Take a Hike

Foundation and community volunteers. Over the past 17 years, we have seen hundreds of students

dramatically increase attendance; expand social and emotional skills; and improve mental and physical

health and well-being. We see about 80% of our students graduate from high school.

TAKE A HIKE OBJECTIVES

Increase student attendance and engagement in school and community.

Engage students to support improvements in their own mental and physical health and well-being.

Improve academic success, leading to high school graduation.

Our ultimate is goal is to assist students to become resilient individuals who can navigate the challenges

of young adulthood after they move on from Take a Hike.

TAKE A HIKE PILLARS

From our rich classroom community, students engage

in:

Academics: students have the opportunity to complete

all courses required for a dogwood diploma.

Adventure-Based Learning: students are engaged in

experiential and land-based learning one day each

week, and during three long wilderness trips.

Community Involvement: connects students to their

community and offers them a chance to give back.

Therapy: embedded registered clinical counsellors

provide students with psychoeducational support.

PROGRAM APPLICATION


APPLICATION PROCESS

This application is to be filled out by the student, with the guidance of the referring adult. Each program

can accept approx. 20 students per year, with intake happening for both September and January, if

needed. Applicants will be notified by a Take a Hike staff member on next steps.

APPLICATION FOR ENROLMENT (TO BE COMPLETED BY THE STUDENT) Name Date of Birth Gender

Y/M/D

SCHOOL INFORMATION Student # PEN #

Ministry / ID #

ESL □ Yes □ No First Language

Do you have Aboriginal Ancestry? □ Yes □ No Do you identify as a visible minority? □ Yes □ No

Ministry of Education Designated □ Yes □ No If yes, designation? □ H □ R □ Q

□ In School Name of current school/program

School-based contact Tel

□ Out of School Last School attended

Last Grade completed Year

Reason for leaving

Number of days attended previous year: Number of days absent previous year: Number of courses completed previous school year:

PROGRAM APPLICATION


CONTACT INFORMATION

Student Phone Number

Student Email

Who do you currently live with, and what is their relationship to you?

Gender of sibling: Age




CONTACT INFO OF PARENTS/GUARDIANS

Parent/Guardian Name: Relationship to you:

Address (please include postal code): Home #:

Cell #:

Work #:

Email Address:

Parent/Guardian Name: Relationship to you:

Address (please include postal code): Home #:

Cell #:

Work #:

Email Address:

PROGRAM APPLICATION


Guardian’s Name: Address (please include postal code): Home #:

Cell #:

Work #:

Email Address:

Other: Address (please include postal code): Home #:

Cell #:

Work #:

Email Address:

OUTSIDE AGENCY INVOLVEMENT Do you have contact with the Ministry for Children and Family Development? □ Yes □ No

Do you have a (please circle those that are relevant)?

Social worker / PO Officer / Counsellor / Therapist / Psychiatrist / Psychologist

If yes, please provide email and phone information:

Name _______________________Tel __________________ Email__________________________

Name _______________________Tel __________________ Email__________________________

Name _______________________Tel __________________ Email_________________________

What other community support agencies do you have contact with? ______

PROGRAM APPLICATION


MEDICAL AND HEALTH FORM

Student Full Name

Birthdate

Address

Doctor Tel

Any health concerns?

BC Medical Number _____________________ Date of last tetanus shot ___________________

Any Additional Insurance?

Do you take prescribed medications (include EPI pens)? □ Yes □ No

If yes, please list: (name, reason, dosage, storage, potential side effects/treatment of such):

Name Reason Dosage/Timing/Special

Instructions

Potential Side Effects

Allergies (ie, food, bee stings):

Please List: Reaction:

PROGRAM APPLICATION


***OFFICE USE – fill out with TAH staff member in Intake Meeting

Storage Requirements:

Potential side-effects:

SERIOUS

COMMON

First Aid for side-effects:

Contradictions:

Who will carry:

Who will administer:

Dentist ___________________________________ Tel_________________________________

Have you had a concussion before? □ Yes □ No

If yes, please explain:

Do you have any health concerns or previous injuries, surgeries, hospitalization that Take a Hike staff

should know about? □ Yes □ No

If yes, please explain: ________________________________________________________________

PROGRAM APPLICATION


Specify activities that this student should no participate in, or modifications that might be required to

participate in field studies

Other Health/Medical/Dietary Concerns/restrictions:

Emergency Contacts

1) Phone: (H) (W) (C)

2) Phone: (H) (W) (C)

ACKNOWLEDGEMENT OF CONSENT*

Specify Parent/Guardian relationship who is participating in filling out and signing this form:

Should it become necessary for my child to have medical care, I hereby give the teacher permission to

use his/her best judgement in obtaining the best of such services for my child. I understand that any cost

will be my responsibility. I also understand that in the event of illness or accident, I will be notified as

soon as possible via the emergency contact information listed above.

Name (please print) Signature

*More discussion and info on this in Intake Interview. Please feel free to wait to sign this until speaking

with a staff member.

PROGRAM APPLICATION


Please have your referral source (high school counselor/youth worker) fill out the next section: School Name __________________________________________________________________________

(School) Counselor Name ________________________________________________________________

Phone Number(s) ______________________________________________________________________

Email Address _________________________________________________________________________

Please describe your relationship to this student:

Based on your understanding of the TAH program (information included in this application package, on

the website or through interaction with program), would TAH be a suitable program for this student?

Please explain why ‘yes’ or ‘no’:

Does this student have a school designation? If yes, please list - ________________________________ Please list documentation found in student file supporting the designation (ie: School Team Minutes, Attendance Records, Behavioural/Mental Health Assessments etc):

Can a Youth and Family Worker from Take a Hike contact you with further questions?

Please circle - YES / NO

PROGRAM APPLICATION


TAKE A HIKE CONSISTENCIES These ground rules have been adopted to ensure safety, maximum participation, and optimal learning in

the classroom and on fieldtrips.

BE ON TIME AT THE START OF THE DAY, AND FOR ALL BREAKS: If you cannot make it on time;

call ahead and leave a message telling us when you will arrive.

RESPECTFUL LANGUAGE: Swearing and put downs are disrespectful and do not belong in the program.

Please express yourself in a pro-social way.

FOCUS: We seek to create an environment that everyone’s voices can be heard and respected. It’s

important to pay attention to the activity and speaker at hand. Staff desire to hear your input and

understand your thoughts and feelings, and will designate time in all activities to give you full attention,

should you need it.

KEEP THE CLASSROOM/CAMP GROUND CLEAN: The classroom and campground are shared by many.

We strive to create and maintain environments that can and would be enjoyed by others.

MUSIC and/or ELECTRONIC DEVICES: Cell phones, mp3 players, iPods, games, etc may NOT be used

during class time, day trips, or multi-day trips.

ABUSE OR VIOLENCE OF ANY KIND: Abuse is defined as anything that is destructive or disrespectful to

self or others. Abuse includes: swearing, sarcastic tone of voice, or loud aggressive tone

Anti-social behaviour such as: racism (including jokes), sexism (any comments which put people

down based on their gender), homophobia (comments about a person’s sexual orientation) Violence is

any physical act which hurts self or another. It includes: Pushing, spitting at another, hitting, scratching,

kicking, etc

RELATIONSHIPS: We strive to create a community where everyone feels welcome. We do this through

creating caring individual friendships, and a cohesive group dynamic.

LEAVING THE CLASSROOM/FIELDTRIP/CAMPGROUND: You must check with a staff person before you

leave for any reason (including bathroom breaks).

NO SMOKING ON SCHOOL GROUNDS OR FIELD TRIPS: Staff will let you know when and where smoking

is permitted.

PROGRAM APPLICATION


FAMILY PARTICIPATION: We understand that parents are the experts on their children, therefore

parental/guardian involvement is crucial for student success in the program. Participation from family

occurs through participation in the students academic and therapeutic process. Should you have

concerns about your child’s performance, staff will make every effort to meet with you.

A field trip starts when you enter the school grounds and ends after clean-when the staff indicates

that the day is complete. These hours may vary on different days.

Student Declaration: I am prepared to attend regularly, to make a commitment, to complete all

assigned work, and to participate fully in all program activities, regardless of the weather. I have read,

understood, and agree to abide by the expectations set by the Take a Hike program.

Signature of Student ______________________________________ Date _________________________

Guardian Declaration: I am fully prepared to support the above student to succeed in this program by

liaising regularly with staff and attending parent/staff meetings as required.

Signature of Guardian _____________________________________ Date _________________________

Signature of Guardian _____________________________________ Date _________________________

PROGRAM APPLICATION


Lastly, please share with us in a short paragraph why you would like to join the Take a Hike program:

PROGRAM APPLICATION


Program and Intake Contact Info:

Burnaby Take a Hike

Grades 10-12

Canada Way Learning Centre

5310 Woodsworth Street, Burnaby BC V5G 1S4

Peter Van Den Hoogen 604-760-0141

Vancouver Take a Hike

Grades 10-12

John Oliver Secondary School

530 East 41st Ave, Vancouver BC, V5W 1P3

Grades 10/11: Adriann Connor 604-713-8255 (available Sept-June)

Grades 11/12: Jay Wade 604-713-8243 (available Sept-June)

West Kootenay Take a Hike

Grades 10-12

Kootenay Columbia Learning Centre

200 Third Ave. Trail BC, V1R 1R6

(serving communities of Castlegar, Fruitvale, Robson Valley, Rossland, Montrose, and Trail)

Chris Gibson 250-364-1275 (available Sept-June)

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Take a Hike - WordPress.com€¦ · Take a Hike is a full-time, alternate high school program for youth who were formerly disengaged. Embedded in the public school system, the program