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Teen Leadership Training Application Packet – 2014
Ages: 13-15 years
How to register for the TLT Program….
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Complete the TLT application form
Read and sign the TLT Expectations and Conduct Agreement
Complete Registration Form
Obtain a copy of current Physical and Immunizations records
Get a letter of recommendation from a teacher/counselor or coach
Mail or drop-off all 5 items to the address below:
Stephanie Dolson
Youth Intervention and Prevention Coordinator
Berkshire South Regional Community Center
15 Crissey Road, Great Barrington, MA 01230
[email protected]
Teen Leadership Training (TLT) Application
Name: __________________________________________________________________________________________________________
(Last)
(First)
(Middle)
Address: _______________________________________________________________________________________________________
City: ____________________________________ State: _________ Zip: ______________ Phone: _________________________
School Attending: ____________________________________________________________________________________________
Grade completed in June: __________
Age: _________
Date of Birth: __________________
Have you ever participated in a Teen Leadership Training program before? If yes which one and
where?__________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Please list any club experience, school organization, or other group(s) that you are a member of:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Please list any volunteer, work, or leadership experience that you have:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Do you currently hold any certifications (including water safety)? If yes, please list?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Please list any hobbies or special interests:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What activities or projects do you enjoy leading or would you feel comfortable leading?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Please answer the following questions as best as you can. Your response does not need to be
lengthy. There are no “right” answers. Please be honest.
Why would you like to participate in the TLT Program?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What goals and objectives do you seek to achieve through the TLT Program?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Please note: TLT’s will need to bring the following items daily: lunch, snack, sunscreen, appropriate
shoes for outside physical activities, bathing suit and towel, money for trip(s) when necessary.
Please retain a copy of these forms for your file.
I certify that my application is true to the best of my knowledge. I understand the expectations of me
as a Berkshire South Regional Community Center TLT. I understand that any false statements shall be
considered sufficient cause for dismissal from the program. I also understand that I need to submit a
letter of recommendation from a current teacher or coach. Included on the letter should be a phone
number and or an email where they can be contacted for further comment.
Applicant’s Signature: __________________________________________________________________ Date:_____________
Parent/Guardian Signature: __________________________________________________________ Date _____________
TEEN LEADERSHIP TRAINING
EXPECTATIONS AND CONDUCT AGREEMENT
At Berkshire South Regional Community Center’s (BSRCC) Teen Leadership Training (TLT)
Program our goal is to provide youth with activities and programs that will improve
academic achievement, self-esteem, and social competence through creating positive selfimage and a feeling of being a part of a caring team!
All of the TLT Expectations are reflective of Berkshire South’s mission. As a TLT, you are
upheld to set policies and regulations that govern staff and TLT’s to ensure that fellow
TLT’s and BSRCC staff will be in a safe atmosphere both emotionally and physically.
BSRCC’s Teen Leadership Training Conduct:
1. Must adhere to the TLT dress code: TLT T-Shirt that is not ripped or frayed or altered.
Clothing must not advertise any tobacco or alcohol products (the TLT shirts are
encouraged to be worn on trips). Shorts must not be cut-offs and must be at least fingertip
length. String Bikini and thong swimsuits are prohibited (appropriate two piece suits are
allowed).
2. TLT’s must follow the provided schedule at all times. Deviation from the schedule
requires approval from TLT Coordinator.
3. No alcohol, tobacco, or illegal drugs are allowed on BSRCC property.
4. Abusive language and actions will not be tolerated. This includes profanity, adult humor
and sexual references. Language, attitude and actions must compliment the BSRCC’s
philosophy and values at all times.
5. Respect for BSRCC staff and property must be upheld at all times.
I understand and agree with all of the above information and realize that failure to comply
may result in dismissal from the program.
TLT Signature: ___________________________________________________________
Date: __________________
Parent Signature: ________________________________________________________ Date: __________________
2014 TLT Conduct Agreement
Teen Leadership Training Registration Form
Teen’s Full Name: ______________________________________________________________________ Date of Birth: __________________
Primary Language: _________________________________ Identifying Marks: __________________________________________
Eye Color: ___________________________ Hair Color: __________________________ Skin Color: ___________________________
Height: ______________________ Weight: ____________________
Gender:  Male
 Female
Teen’s Email: ________________________________________________________________________________________________________
Is there a custody agreement, restraining order or other court order in place pertaining to this student?
 Yes
 No (If yes, please attach a copy for our records, which will be kept confidential.)
 Yes
 No (If yes, please provide copy so we can do our best to meet each student’s needs.)
Is an IEP or behavior plan in place for this student?
Parent/Guardian 1
Parent/Guardian 2
Name: _________________________________________________
Home Phone: (______)____________-___________________
Cell Phone: (______)____________-____________________
Work Phone: (______)____________-___________________
EMail: ________________________________________________
Address:______________________________________________
________________________________________________________
City, State: ___________________________ Zip:___________
BSRCC Member:  Yes
 No
Primary Language: __________________________________
Does child reside with this parent/guardian?
 Yes
 No
This parent/guardian will be considered
authorized to pick up the student unless specified
otherwise in the attached custody agreement.
Name: _________________________________________________
Home Phone: (______)____________-___________________
Cell Phone: (______)____________-____________________
Work Phone: (______)____________-___________________
EMail: ________________________________________________
Address:______________________________________________
________________________________________________________
City, State: ___________________________ Zip:___________
BSRCC Member:  Yes
 No
Primary Language: __________________________________
Does child reside with this parent/guardian?
 Yes
 No
This parent/guardian will be considered
authorized to pick up the student unless specified
otherwise in the attached custody agreement.
I would like my teen, ________________________________________________, to attend the Teen Leadership Training
program at Berkshire South Regional Community Center. I will be financially responsible for the
following session(s).
Rates:
$15 per session (sorry no pro-rates)
Sessions:
 Session I CORE only: June 30 - July 18*
 Session II CORE: July 21 - August 8
 Session III CORE: August 4 - August 22
*no class on July 4th
 Session I ADVANCED: June 30 – July 18*
 Session II ADVANCED: July 21 - August 8
 Session III ADVANCED: August 4 - August 22
Advance registration is required. No teenager will be enrolled without a complete registration
packet, including physical form and immunizations, on file.
Payment is due at the start of each session. If necessary, please call to make other payment
arrangements.
I understand:
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I am financially responsible for the sessions I have chosen for my teen.
There is no reimbursement for sick or cancelled days, and I am responsible for my commitment to
the program. Any changes must be put in writing and will only be recognized after a 30 day
period. During the period the director will review the request and make a final determination.
Refunds will not be given for late arrivals, early departures, or missed days.
Billing Address: ______________________________________________________________________________________________________
City/Town: _________________________________________________ State: __________________ Zip Code: __________________
Parent/Guardian Signature: __________________________________________________________ Date: _______________________
FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM
Teen’s Full Name: ______________________________________________________________________ Date of Birth: __________________
I authorize Berkshire South Regional Community Center Staff, trained in the basics of CPR and first aid, to
give my teen first aid care including CPR when appropriate.
I understand that every effort will be made to contact me in the event of an emergency requiring medical
attention for my teen. However, if I cannot be reached, I hereby authorize Berkshire South Regional
Community Center Staff to transport my teen to the nearest medical care facility and/or to
___________________________________________________________, and secure necessary medical treatment for my teen.
Teen’s Physician’s Name: _____________________________________________ Phone Number: ___________________________
Address: ______________________________________________________________________________________________________
Serious illnesses and/or hospitalizations:_________________________________________________________________________
Special physical conditions and/or health conditions: ___________________________________________________________
Dietary Restrictions: ________________________________________________________________________________________________
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions: ___________________________________
_________________________________________________________________________________________________________________________
Please list any rescue medications prescribed for your child (i.e. EPI Pen, Inhaler):___________________________
_________________________________________________________________________________________________________________________
Regular medications: ________________________________________________________________________________________________
If your teen requires emergency medication or is to receive medication while attending
TLT, you MUST have one Medication Authorization Form for EACH prescription or over the
counter medication you send with your teen. All medications, except rescue medications
must be turned in to the TLT coordinator.
Is there an Individual Health Plan for student with a chronic health condition?
(If yes, please attach.)
 Yes
 No
Parent/Guardian Signature: _______________________________________________________ Date: _______________________
Parent/Guardian Emergency Contact Information:
Name:______________________________________________ Address:_________________________________________________________
Home Phone:______________________________________ Cell Phone: _____________________________________________________
Work Phone:______________________________________ Work Hours:____________________________________________________
Parent/Guardian Emergency Contact Information:
Name:______________________________________________ Address:_________________________________________________________
Home Phone:______________________________________ Cell Phone: _____________________________________________________
Work Phone:______________________________________ Work Hours:____________________________________________________
BERKSHIRE SOUTH REGIONAL COMMUNITY CENTER POLICY
Teen’s Full Name: ______________________________________________________________________ Date of Birth: __________________
I understand that BSRCC allows youth at the age of 13 to be without a guardian in the center. We do ask
that your teen sign in to the TLT program in the morning and sign out at the conclusion of the day. We
also ask that you complete the following emergency contact list so that we have additional emergency
contacts for your teen.
Emergency Contacts (in addition to parents/guardians listed on reverse)
Name: ___________________________________________________ Relationship to Teen: ___________________________________
Home Phone:_____________________________________________ Cell Phone: ______________________________________________
Address: ______________________________________________________________________________________________________________
Name: ___________________________________________________ Relationship to Teen: ___________________________________
Home Phone:_____________________________________________ Cell Phone: ______________________________________________
Address: ______________________________________________________________________________________________________________
Name: ___________________________________________________ Relationship to Teen: ___________________________________
Home Phone:_____________________________________________ Cell Phone: ______________________________________________
Address: ______________________________________________________________________________________________________________
Name: ___________________________________________________ Relationship to Teen: ___________________________________
Home Phone:_____________________________________________ Cell Phone: ______________________________________________
Address: ______________________________________________________________________________________________________________
If you have additional emergency contacts, please add them on a separate sheet.
Parent/Guardian Signature: _______________________________________________________ Date: _______________________
TRANSPORTATION PLAN & AUTHORIZATION
Teen’s Full Name: ______________________________________________________________________________________________
My child will arrive at the program:
 Parent Drop Off
 Supervised Walk
 Unsupervised Walk
 Public/Private Van
 Contract/Van
 Private Transportation Arranged by Parent
 BSRCC Van
 Other: ___________________________
My child will depart from the program:
 Parent Pick Up
 Supervised Walk
 Unsupervised Walk
 Public/Private Van
 Contract/Van
 Private Transportation Arranged by Parent
 BSRCC Van
 Other: __________________________
Parent/Guardian Signature: _______________________________________________________ Date: _______________________
REFER TO FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM FOR RELEASE INFORMATION
PERMISSION FORM
Teen’s Full Name: ______________________________________________________________________________________________
Sunscreen & Insect Repellent:
As much as possible, we will be doing our team building exercises outside. That means the skin is more
exposed, we want to be sure teens are protected from the sun and insects. We encourage you to send
sunscreen and insect repellant with your teen daily. They will be encouraged to apply it themselves as
often as needed.
Photographs:
Occasionally we take photographs of the students for classroom bulletin boards and other use within the
Center. Please check if you do ____ or do not ___ authorize the use and reproduction of these photographs
for TLT and Center use. A separate form is included in this packet to provide permission for use of
photographs in BSRCC marketing materials.
Offsite Activities:
Several times during each TLT session, teens will go on field trips. Some of the trips are within walking
distance, and others require transportation. The field trips will consist of canoeing trips, hiking
excursions, assisting in caring for the Action Adventure campers on one or more of their field trips, and
meeting local business owners. When we do have a field trip, you will be notified about it beforehand.
I do ____ or do not ___ give my teen permission to participate in offsite activities. I recognize that I will be
notified in advance of all field trips and that transportation for offsite trips, not in walking distance, will
be provided in BSRCC vehicles with qualified drivers.
Parent/Guardian Signature: _______________________________________________________ Date: _______________________
BERKSHIRE SOUTH REGIONAL COMMUNITY CENTER MINOR RELEASE
In consideration of the engagement as a model of the minor named below, and for other good and valuable
consideration herein acknowledgement as received, upon terms herein stated, I here by grant Berkshire
South, its Executive Director and any and all staff, her legal representatives and assigns, those for whom
________________________________________________________ is acting, and those acting with her authority and
permission, the absolute right and permission to copyright and use, re-use and publish photographic
portraits or pictures of the minor or in which the minor may be included, in whole or in part, or composite
or distorted in character or form, without restriction as to changes or alterations from time to time, in
conjunction with the minor’s own or fictitious name, or reproductions thereof in color or otherwise made
through any media at her studios or elsewhere for art, advertising, trade, or any other purpose
whatsoever. I also consent to the use of any printed matter in conjunction therewith.
I hereby release, waive any right that a minor or I may have to inspect or approve the finished product or
products or the advertising copy or printed matter that may be used in connection there within or the use
to which it may be applied.
I hereby release, discharge and agree to save harmless Berkshire South Regional Community Center, its
executive director and any staff her legal representatives or assigns, and all persons acting under her
permission or authority or those whom she is acting, from any and all liability by virtue of any blurring,
distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may
occur or be produced in the taking of said pictures or in any subsequent processing thereof, as well as any
publication thereof even though it may subject the minor to ridicule, scandal, reproach, scorn and
indignity.
I hereby warrant that I am of full age and have every right to contract for the minor in the above regard. I
state further that I have read the above authorization, release and agreement, prior to its execution, and
that I am fully familiar with the contents therein.
Minor’s Name: _________________________________________________________Date:__________________________________________
Signature: (Father) (Mother) (Guardian)
Printed Name:
Address:__________________________________________________________________ Phone:_____________________________________
City: _____________________________________________________________State: ____________________ Zip: ______________________
Witness: ____________________________________________________
Dear Physician:
This child is enrolled in a teen leadership program licensed by the Department of Public Health. DPH
regulations require at the time of admission, a written statement from a physician as evidence of each
child’s annual physical examination, along with immunizations and lead screening in accordance with the
Department of Public Health’s recommended schedules. A prompt response is appreciated.
Evidence of a physical exam is valid for one year from the date the child was examined and must be
renewed annually thereafter.
Child’s Name: ________________________________________________________________________ Date of Birth: _____________________
Parent/Guardian Names: ___________________________________________________________________________________________
Address: _____________________________________________________________________________ Phone: _______________________
Date of Examination of Child: ___________________________________________________________
What is your opinion concerning the child’s general health and appearance?
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Has this child been screened for lead poisoning?
If yes, date screened: ________________________
 Yes
 No
Does this child have any disabilities or chronic medical problems (allergies, limited vision etc.) which
require special consideration or care by the child care provider? If so, please detail below:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Physician Name: ________________________________________________________________ Phone: ____________________________
Physician’s Signature: ____________________________________________________________ Date: ____________________________
Comments: ___________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Please attach a copy of the child’s most recent immunizations. Thank you!
Please return to: Teen Leadership Training
Berkshire South Regional Community Center
15 Crissey Road, Great Barrington, MA 01230
Fax: 413-528-5260 Phone: 413-528-2810 ext. 30