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 Watauga High School, The United Way, The Town of Boone, and Watauga County 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. Students should plan on participating in the Climbathon on October 4th which is our largest student fundraiser of the year. 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! Shelly Robinson Executive Director Mountain Alliance, Inc.
Mountain Alliance Leadership Development Program Application Name ____________________________________________________________________________ Last
Address ___________________________________________________________________________ Address
Student Phone: __________________ Do you text? _______ 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,
TOBACCO PRODUCTS ,
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 students 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
_______________________________________________ Signature of Parent/Legal Guardian
Mountain Alliance, Inc. Mountain Alliance, Inc. Parental Consent Form Participantâ€™s Name _____________________________________________________________________ Parentâ€™s Name(s) ___________________________________Phone(h)_____________(w)_____________ ___________________________________Phone(h)_____________(w)_____________ Parentâ€™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.
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.
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.
Participation I give my permission for my child to participate in all Mountain Alliance programs. Semester calendars are available at the Mountain Alliance office or on our website www.mountainalliance.org
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
_________________________________________ Signature of Participant
Participant Health Information Participantâ€™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? â€Ś.. 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
Does participant get carsick? ________________________________________ Other factors we should be aware of to care for your child: ______________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
_________________________________________ Signature of Parent/Legal Guardian