Fill out and return to: Youth Leadership Genesee,
Resource Genesee, 1401 S. Grand Traverse, Flint, MI 48503
Or Fax to (810)232-3738.
At this time you cannot fill the application out on line or submit it via email.
YOUTH LEADERSHIP GENESEE
Leadership That Makes a Difference!
2010-11 APPLICATION
Due date: 10-20-2010
A program of
Date
Name
Home Address
Home Phone
Student Cell Phone
Home E-Mail
Facebook/MySpace etc:
Birth date
Parent(s)/Guardian(s)
Parent Day Phone 1
Parent Day Phone 2
Parent E-Mail
Voice Mail/Direct Dial
Bus. E-Mail
Cell Phone: Other
Ethnicity: Asian Pacific African American Caucasian
Hispanic Native American
Other:
_____I do not wish to disclose this information.
Gender:
Female Male Shirt Size: ____________
Do you have any special dietary needs or will you require special accommodations?
Yes No
Please attach your requirements to this application.
School Grade GPA
Sponsoring Organization (if other than school)
School or Organization Contact Name
Email Phone General Information
General Information
1. Describe your plans for involvement for this coming year in school and community activities:
2. Identify community groups, organizations, or projects that you’d like to learn more about through YLG:
3. What do you think are the most important characteristics of a good leader?
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4.What things about leadership would you like to learn as a result of this program?
5. In your opinion, what are the three most significant challenges facing Genesee County?
a.
b.
c.
6. In your opinion, what are the three most notable opportunities Genesee County has to offer?
a.
b.
c.
7. If you had to choose one thing to make a difference about, what would it be?
8. What career choices have you thought about pursuing?
9. How did you hear about Youth Leadership Genesee (formerly Greater Flint Youth Leadership)?
10. Please tell us why you want to participate in Youth Leadership Genesee:
11. Anything else you’d like the selection committee to know about you or your involvement with YLG?:
References
Please list two references who can be contacted for additional information.
Name Title Organization Phone
If selected as a participant in Youth Leadership Genesee 2010-11, I will attend the Team Building retreat and at least 75% of the monthly sessions, 2 of 3 volunteer project dates, 2 of 3 general days and the New Leaders Dinner. I understand that it is my responsibility to get to the program each day. I will also make every effort to attend all of the events sponsored by the program. I understand that if I fail to meet any part of this commitment, I may be asked to withdraw from the program without any refund of tuition. I understand that any false information may disqualify me from the program. I give permission to have photos and videos of me / of my child as a participant used for promotional purposes.
Student Signature Date
Parent Signature Date
School / Sponsoring Organization Commitment
The Applicant has our full support including the time required to participate in the program.
Name/Title
(Please Print)
School/Organization
Title Date Signature
Tuition will be paid by: Student School / Sponsoring Organization
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Please return completed application, $50 Payable to : “RESOURCE GENESEE” to:
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For further information: Jim Ananich
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Youth LEADERSHIP GENESEE
c/o Resource Genesee
1401 S. Grand Traverse
Flint, MI 48503
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Phone: (810) 348-1498
Fax: (810) 232-3738
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BASE CAMP ACKNOWLEDGMENT AND RELEASE FORM
Have you been to Base Camp before? Yes □ No □
Group Name/Time: Youth Leadership Genesee Circle One: PARTICIPANT or NON-PARTICIPANT
Name (please print): Date of Birth:
Address:
(street) (city) (state) (zip)
Telephone:
E-Mail: _________________________________________________
Allergies:
Current Medical Conditions:
Family Doctor:
(Name) (phone)
In case of emergency, notify:
Name: Telephone:
I understand that participation in this program like any other situation involving height and movement involves risks and dangers including but not limited to those of bodily injury, partial and/or total disability, paralysis and death. These risks and dangers may be caused by the negligence of the participants or the negligence of others. There may be other risks not known thus or are not reasonably foreseeable at this time. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, Hereby release, Indemnify, and hold harmless the Base Camp at GASC Technology Center, their officers, officials, agents and/or employees, other participants, sponsoring agents and advertisers. With respect to any and all injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.
We strongly advise against bringing children that are not participating in Base Camp organized programming. Unsupervised children will be asked to leave.
Photographs and video images taken while at Base Camp may be used to illustrate Base Camps adventure education programs. Please Check One: Yes, you may use my image: ________ No, you may not use my image: ________
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND THE TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
ALL SIGNATURES MUST BE IN INK.
(Participant signature if 18 or older) (Date)
FOR PARENTS/GUARDIANS OF PARTICIPANTS
This is to certify that I, as parent/guardian with legal responsibility for this participant, so consent and agree to his/her release as provided above all the Releases, and for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my child’s involvement or participation in these programs as provided above, even if arising from the negligence of the releasees, to the fullest extent permitted by law.
(Print Parent/Guardian name)
X
(Parent/Guardian’s signature) (Date)
YOUTH LEADERSHIP GENESEE RELEASE FORM
Note: A release form is needed from each participant.
Name _____________________________________ Phone _______________________
Address _______________________________________________________________________
Email Address___________________________________________________________________
Emergency Contact ___________________________ Phone _____________________
LIABILITY RELEASE: I hereby release, indemnify and hold harmless Resource Genesee, the organizers, partners, sponsors and supervisors of all its activities, from any and all liability in connection with any injury (including any injury caused by negligence), in conjunction with volunteer projects.
Signature _____________________________________
Date _____________________________
COMMUNICATIONS RELEASE: I hereby give to Resource Genesee, and to its nominees, agents and assigns, my free and unlimited consent and permission, waiving all claims for any compensation by reason thereof or for damages by reason thereof, to use, publish, republish, sell or exhibit in the furtherance of its work, with or without identification of me by name, the photographs, videos, recordings or statements taken and to disseminate statements referring to me in conjunction therewith if Resource Genesee so desires and to authorize any newspaper, company or other organization to use, publish, republish or exhibit said photograph with or without identification of me by name and to publish or disseminate statements referring to me in conjunction therewith in the promotion of Resource Genesee and any of its fund campaigns or any of its activities.
Signature _____________________________________
Date _____________________________
PARENTAL CONSENT/RELEASE If the individual is a minor (under 18 years of age), the following should be signed by a parent or legal guardian.
I hereby consent and agree, individually, and as a parent or legal guardian of
_________________________________________________ to all the terms and provisions above.
Signature _____________________________________
Date _____________________________
Name (Please Print) ______________________________________________________________
Address ______________________________________
Relationship to minor ________________
Resource Genesee, 1401 S. Grand Traverse St., Flint, MI 48503
(810)767-0500, www.resourcegenesee.org