Rooted & Rising Student Application – Seldovia Village Tribe

Rooted & Rising Student Application

- Step 1 of 12

Directions

Please complete all portions of the application. Incomplete applications will not be considered.

Note: You must be an Alaska Native student entering 9th-12th grade. Please provide a copy of your Certificate of Degree of Indian Blood (CDIB), tribal enrollment card, or proof of Title VI status. Feel free to contact Christine Brandon Project Coordinator, for more information: (907)435-3264 or cbrandon@svt.org

Student's Name *

First

Middle

Last

Physical Resident Address *

Address Line 1

City

State

Zip Code

Mailing Address (if different)

Address Line 1

City

State

Zip Code

Student's Home Phone *

Student's Cell Phone *

Student's Email Address *

Sex: *

Date of Birth *//

Age *

Grade Level *

School Information

Name of School Currently Attending *

School District *

School Phone *

Principal's Name *

First

Last

Principal's Phone *

Principal's Email *

STUDENT EMERGENCY INFORMATION

Student's Name *

First

Middle

Last

Birthdate *

Parent/Legal Guardian Name *

First

Last

Parent/Legal Guardian Home Phone *

Parent/Legal Guardian Cell *

Parent/Legal Guardian Business Phone *

Parent/Legal Guardian Email *

Parent/Legal Guardian Name

First

Last

Parent/Legal Guardian Home Phone

Parent/Legal Guardian Cell

Parent/Legal Guardian Business Phone

Parent/Legal Guardian Email

EMERGENCY CONTACT PERSON

(other than parent/legal guardian)

Name *

First

Last

Home Phone *

Cell Phone *

Business Phone *

Email *

PRIMARY CARE PROVIDER

Full Name *

Primary Care Provider's Phone *

Do you have Health Coverage/Medical Insurance *

Do you have Denali Kid Care? *

Denali Kid Care ID# *

Do you have Medicaid? *

Medicaid ID# *

Name of Health Insurance *

Name of Insured *

First

Last

Group/Policy Number *

ID Number *

MEDICAL INFORMATION FORM

Name *

First

Middle

Last

Please answer each question below - All information is required.

Does your child have any medical/physical condition or diagnosis we should be aware of? *

(please check all that apply) *

Diabetes (Type 1/Type 2)
Deaf/Hard of Hearing
Seizures/Epilepsy
Chronic or Recurring Illness/Condition
Assistive Devices (Walker, Wheelchair, Braces, Hearing Aid, etc.)

Other(s) Allergies or dietary restrictions:

Does your child have a mental/behavioral health concern and/or diagnosis we should be aware of? *

(please check all that apply) *

Reactive Attachment Disorder (RAD)
FASD (Fetal Alcohol Spectrum)
Oppositional Defiance Disorder (ODD)
PTSD (Post Traumatic Stress Disorder)
ADD/ADHD
Bipolar
Depression
Anxiety Disorder
Personality Disorder
OCD
Autism
Emotional health concerns of any type
Currently seeing professional for mental/emotional health concerns

Other(s):

MEDICAL INFORMATION FORM (continued)

Does your child receive any special services through the school district? *

(E.g., IEP, IFSP, 504 Plan, Behavioral Support Plan, Resources, Gifted, OT/PT, Speech, etc.)

Please Explain:

Does your child take any prescription or over-the-counter medication? *

Medication *

(please list the name, dosage, time taken and reason for any medications)

Dosage *

Time Taken *

Reason for Medication *

Medication

(please list the name, dosage, time taken and reason for any medications)

Dosage

Time Taken

Reason for Medication

Medication

(please list the name, dosage, time taken and reason for any medications)

Dosage

Time Taken

Reason for Medication

Does your child have any emotional support needs or behaviors we should be aware of? *

(please check all that apply) *

Is your child easily distracted or struggle to focus on structured activities or work?
Does your child struggle with quiet, low energy or independent activities?
Does your child ever get easily overwhelmed?

If yes, what may that look like?

Does your child struggle to manage feelings of frustration, sadness, or anger?

Other(s):

Registering Parent/Adult Name(s) *

First

Last

Date *

Name

First

Last

Date

Permission to Obtain High School Transcripts and Standardized Test Scores

I give permission to my child’s current school and teachers to release academic information about my child, including their attendance records, grades, standardized test scores, and/or Individualized Educational Program (IEP), to SVT’s Rooted and Rising Project Coordinator and project Evaluator. I give permission for the school district or school in which my child is attending to send via email, mail or fax any or all of these records to the SVT Project Coordinator which also involves collecting my child’s 8th -12th grade standardized test scores and attendance as they progress through school after Camp. *

I agree

SVT's access to transcripts and test scores will not affect your standing in our program.

Please sign and date below to grant permission for SVT’s Rooted & Rising staff to access your transcripts and standardized test results.

Student Name *

First

Last

Student Signature *

Date *

If the applicant is under 18 years old, Parent/Legal Guardian – please sign below:

Parent Name *

First

Last

Parent Signature *

Date *

Student Questionnaire

Directions: Please answer the following questions in your own words.

1. What do you expect to gain from attending Rooted & Rising Camp? *

2. What positive qualities do you think you bring to the camp? *

Examples: I have a great sense of humor; I am a hard worker; I like learning new things.

3. What do you think might be the most challenging for you while attending camp? *

4. What activities do you participate in during your free time? *

5. What are three things that are very important to you? *

Camp Requirements

The camp requires applicants to be willing and able to fully participate and attend the 13 to 15-day camp located in Kachemak Bay. Students are expected to attend and participate in all activities throughout the camp, as well as participate in coaching sessions in the nine months following camp. Participants need to be able to manage themselves and demonstrate a respectful attitude towards others. They also need to show a desire and willingness to learn and give back of themselves to all that will be working with them.

Camp Agreement

I agree to participate fully in the 13 to15-day Rooted & Rising Camp. I realize I will not be able to easily go home once I have come to camp and agree to take care of myself and manage my emotions and behaviors to be respectful towards the staff and other participants involved. I agree to keep the agreements I make. *

I agree

Student Signature *

Date *

Coaching Agreement

I agree that I will participate in coaching sessions with my mentor coach discussing and tracking my personal goals throughout the next school year. *

I agree

Student Signature *

Date *

Parent/Guardian Agreement

My son/daughter/ward has my/our permission to apply for, and participate in, the Rooted & Rising camp for summer 2021.

Parent/Guardian Signature *

Date *

Student Code of Conduct

Check each section and sign below with your parent or legal guardian

I agree to respect the rights and property of others.
I agree to respect adult leaders and other participants.
I understand that all socializing will take place only in public areas. No visiting is permitted in the sleeping area that I am not assigned to.
I will be in my assigned room/tent by the 10:00 p.m. curfew each night.
I will be on time for and fully participate in all activities.
I agree to not leave an event, unless my adult leader grants permission.
I agree to be open to building new relationships with my peers and adult leaders.
I will NOT possess any drugs, tobacco, vape pens, drug paraphernalia, alcohol, fireworks, matches, cigarette lighters, knives, firearms, ammunition and explosive materials or items that would endanger people, pets, wildlife, or property or are illegal.
I will refrain from fighting or any other actions that may cause harm to others.
I will refrain from any sexual misconduct.
I will refrain from body alterations including but not limited to piercing and tattoos.
I will not use a cell phone, iPod, game and/or other handheld device during any group activity, event and class. ((No power available in cabins to keep units charged over camp duration.)
I will not have visitors except at designated events and by permission of staff.
I will abide by the laws and regulations of the State of Alaska, the Kenai Peninsula Borough, the Seldovia Village Tribe, and the City of Seldovia.

Student: I understand that camp participation involves risks from involvement in group activities which can be difficult to predict or control. I understand the need to agree to the above items. I realize and agree that if I do not abide by these rules, I may lose the privilege of participating in Rooted & Rising Camp, and may be sent home at the discretion of the adult leader and at my parent/guardian’s expense. I will be responsible for all consequences of my behavior. *

I agree

Parent/Legal Guardian: Additionally, as the parent/legal guardian of the participant in this camp, I agree to release and hold harmless the Seldovia Village Tribe from any and all liability associated with my/my child’s participation in the Camp. *

I agree

Student Signature *

Date *

Parent/Legal Guardian Signature *

Date *

Permission for Medical Care and Release of Liability

In consideration of the acceptance and participation of the applicant in such program, the undersigned APPLICANT and his or her PARENTS or LEGAL GUARDIANS, to the full extent permitted by law, hereby agree to release SVT and its directors, officers, employees and agents, and representatives from any and all liability, loss, damage claim and/or cause of action, known or unknown, of any kind that may arise in connection with my/my child’s participation in Rooted and Rising camp, including any liability, loss, damage claim and/or cause of action which may be caused by their negligence or willful neglect. I also agree to defend, indemnify and hold harmless SVT, and its directors, officers, employees, agents, and representatives from any and all liability, loss, damage claim and/or cause of action of any kind that may arise as a result of my own actions, or those of my child, or conduct as a participant in Rooted & Rising, including travel to and from the home community.

I understand that Rooted & Rising does not provide medical insurance, which would cover a student’s injuries or actions. It will be my/our responsibility as parents or legal guardians to provide payment for such expenses should they occur, including emergency transportation costs. I am aware of the hazards associated with participation in this activity.

We, the parents/legal guardians of the applicant, who have the sole and legal right to make the decisions on the health and care of the applicant do release from liability and grant permission as noted of the following while our son/daughter/ward is outside of their home community as a Rooted & Rising participant: *

● In the event of accident or sickness, we/I authorize any employee of Rooted & Rising for our son/daughter/ward to select the appropriate medical facility and physician(s)/dentist(s) to provide treatment and/or to coordinate emergency transportation;
● We/I give permission for any operation, administration of anesthetic or blood transfusion which a medical practitioner may deem necessary or advisable for the treatment of our son/daughter/ward;
● We/I further consent to any medical or surgical treatment by a licensed physician, surgeon or dentist, which might be required by our son/daughter/ward for any emergency situation. We do request that we be notified as soon as possible, but emergency treatment need not be delayed to provide such notice.

Applicant Name *

First

Last

Applicant Signature *

Date *

Parent or Legal Guardian Name *

First

Last

Parent or Legal Guardian Signature *

Date *

Parent or Legal Guardian Name

First

Last

Parent or Legal Guardian Signature

Date

PARTICIPANT RISK ACKNOWLEDGMENT, ACCEPTANCE AND RELEASE

You may participate in activities where risk may be greater than what you normally encounter in your day-to-day routine. For your own personal safety and well-being as a participant in Rooted and Rising you need to plan ahead to make sure your experience is safe. During the pre-travel session the staff from SVT and Rooted & Rising and its contractor(s) or subcontractors will discuss with you the basic rules of safety while staying in your camp community. Following these instructions, you must exercise common sense and personal awareness to reduce the element of risk and injury to yourself and others. However, it will be impossible for SVT and Rooted & Rising staff and your host community to eliminate all hazards or to guarantee your safety against all risks. You must take personal responsibility for your own safety and the safety of others participating in the program. Act reasonably, prudently, and exercise common sense and good judgment throughout your experience with Rooted and Rising. To emphasize the importance of this, you and your parents or legal guardian must read and return the following acknowledgment of risks and release.

1. Acknowledgement of Risk

I agree that the risks associated with the camp are as follows: Although SVT, Rooted & Rising, its contractor(s) or subcontractors and its staff and program representatives have taken reasonable steps to inform me that the activities offered through Rooted & Rising include risks, including risks which are inherent and cannot be eliminated without destroying their unique character, these inherent risks can be causes for the loss or damage of my personal belongings, accidental injury, illness, or in extreme cases, permanent trauma or death. The following describes some but not all of those risks. *

I agree

2. Description of Activities and Inherent Risks

As a participant in Rooted & Rising, you will be transported to and from your home community by commercial plane. Upon your arrival in your host community, the mode of transportation within the community and surrounding areas may include automobile, over improved or unimproved roads, and by ATV, and/or boat or ferry. During your stay you may participate in, observe or be exposed to a variety of activities, indoor and outdoor, such as: swimming, kayaking, hiking, on and off roads, trails and highways, being involved in a vehicular accident, and exposure to natural disasters such as earthquakes, tsunamis or forest fires. The following are some, but not all, of the inherent risks which may be encountered: animal encounters, risks of cold or heat injury, insect or other animal bite, and losing balance on wet, frozen or uneven surfaces. The risks of the activities may include but are not limited to drowning, fractures or broken bones, torn muscles and/or ligaments, sprains, strains, sunburn, windburn, cuts and internal and external injuries with bleeding. When traveling by boat you may be in open water and be exposed to waves, tides, and powerful currents and may encounter violent storms and sea mammals. You may also be exposed to risks associated with capsizing or sinking in extremely cold waters, which may expose you to hypothermia or accidental death. *

I agree

3. Acknowledgment of Risks and Release

I am aware that the activities associated with this trip entail risk of injury or death to any participant. I acknowledge that Rooted & Rising recommends that I never travel alone. Going out on your own, especially at night, may present additional danger to my safety and well-being. I have read the description of risk activities contained in this statement, and I understand the description of these inherent risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death. I agree to assume and accept full responsibility for the inherent and unanticipated risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary, and I elect to participate in spite of and with full knowledge of the inherent risks. I acknowledge that engaging in this activity may require a degree of skill and knowledge different from other activities that I have participated in the past. I represent that I am in good shape and have met the criteria for participation in this activity and that I have signed the medical release form. I certify that I am fully capable of participating in the activities. Therefore, I assume and accept full responsibility for myself, for bodily injury, death, or loss of personal property and expenses as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence in participating in this activity. I have carefully read and clearly understand and accept the terms and conditions stated herein and acknowledge that this agreement may be effective and binding upon myself, my heirs, assigns, personal representative and estate, and for all members of my family, including minor children. By entering this Agreement, I release Seldovia Village Tribe, and its employees, from all liability for any loss or injury, of whatever kind or nature, may arise from the risks disclosed and acknowledged in this release, including liability arising out of the releases parties’ negligence. *

I agree

Student Name *

First

Last

Student Signature *

Date *

Parent or Legal Guardian Name *

First

Last

Parent or Legal Guardian Signature *

Date *

Parent or Legal Guardian Name

First

Last

Parent or Legal Guardian Signature

Date

Student Media Release Form

For and in consideration of the opportunity and privilege of appearing in or participating in one or more video recordings, soundtracks, films, photographs, written articles, internet, or recordings, I hereby consent to the use and editing thereof and release Seldovia Village Tribe and their employees and assignees from any and all claims resulting from such use, sale, editing and release to the newspaper and/or television stations/channels.

Student Signature *

Date *

Parent or legal guardian signature is required if the participant is under 18 years of age.

Parent or Legal Guardian Signature *

Date *

T-Shirt/Sweatshirt Size *

Comment