Moose Youth Awareness Congress Registration Complete, sign and send original parental form and copy for your record and use for the “Kids-talk” presentations. (Minimum of Three per student) Student form must be returned w/check payable to the “PMA”, along with original Parental forms. Students may not leave your lodge (home), if forms are not returned. (Select the appropriate congress by circling at top of the registration form.) Definition of a Chaperone, also special memo Tentative agenda, has dates and places of PMA Youth Awareness congresses for you and your students to make a selection from the list. Thank You, Fraternally Yours, Matthew Reik PMA Youth Awareness Coordinator MOOSE YOUTH AWARENESS PROGRAM 2014 - 2015 ASSOCIATION CONGRESS CONSENT FORM I, the undersigned parent/guardian of _______________________________________________ (“my child”), a minor, hereby give my consent for him/her to attend the Moose Youth Awareness Congress at ________________________________________________ on __________________, 20__. In consideration for my child being allowed to participate in this event, I hereby authorize the provision of all necessary emergency (as defined by local and national medical standards) medical care to my child (including medical, dental and/or surgical) and attach a current, valid copy of my medical insurance card to this agreement. I agree that neither Moose International, Inc. (“MI”), the _________________________________________ Moose Association (“Association”), nor __________________________ Lodge No. ______, Loyal Order of Moose, Inc. (“Lodge”) shall have any financial responsibility for the emergency medical care provided to my child. I also agree to fully defend, indemnify and hold harmless the Lodge, the Association and MI, their respective agents, volunteers, employees, directors, officers, successors and assigns from and against any and all losses, damages, claims and causes of action brought by or on behalf of my child, with the exception of losses arising from their sole gross negligence. I further agree this agreement shall be binding upon my heirs, successors and assigns. REGISTRATION INFORMATION Student’s Name: ________________________________________________________ Sex (circle one) Male Female DOB___________ Class of 20______ Parent/Guardian Name(s): ____________________________________________ Address: ____________________________________________ E-mail address:_________________________________ City: _______________________________State/Province: _______Zip: ___________ Phone: ____________________ School Name: ________________________________________________________School Phone: __________________ Address: ___________________________________________________________________________________________ City: _________________________________________________________State/Province: ________Zip: ___________ PUBLICITY RELEASE Moose International may use my name and photograph in publicity concerning the 2014-2015 Moose Youth Awareness Program. _________________________________________ Signature of Student Representative Dated this ___________ day of __________________________, 20__. ________________________________________________ Parent/Guardian signature Parental Consent form ________________________________________________ Parent/Guardian signature STUDENT FORM 2014 PMA YA Student Congress Windber FC # 349 Selinsgrove FC # 1173 (Circle one) Lodge/Chapter Name & Number _____________________________ Student Name _____________________________ M/F $80.00 Student Name _____________________________ M/F $80.00 Chaperones Name _______________________ per room $95.00 ________________________ Total $_______ Reminder: Students should have writing materials for congress to take notes. DUE DATES; ** Windber FC 349 - October 24, 2014 Selinsgrove FC 1173 – October 31, 2014 **After due date rates will increase $15.00 Final Deadline; Windber FC 349 - October 31, 2014 Selinsgrove FC 1173 – November 07, 2014 Make check payable to: “P.M.A.” and earmark in memo – 2014 PMA Youth Awareness MAIL TO: Matthew Reik 320 Summit Drive, Lewistown PA 17044 This Form must be returned along with original parental forms. PMA YA Student Form MRR-2014 Windber Moose Family Center # 349 1312 Jackson Ave Windber, Pa. 15963 Motel Address: Comfort Inn & Suites 455 Theatre Drive Johnstown, Pa. 15904 Phone: 814-266-3678 (Reservations will be made by YA Coordinator) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Selinsgrove FC # 1173 40 W Spruce Street Selinsgrove, Pa. 17870 Motel Address: Comfort Inn 613 N Susquehanna Trail Selinsgrove, PA 17870 Phone: 570-374-8880 (Reservations will be made by YA Coordinator) PMA YA Student Form MRR-2014 PMA YA CONGRESS CHAPERONES It is recommended that the Lodge or Chapter chairperson be the Chaperone. Chaperones are required to check students into the hotel, pizza party, and Saturday’s congress. They are responsible for students during the congress weekend, Friday night social, as well as attending the congress with the students. There will be no students leaving the pizza party unaccompanied by a chaperone. You are also responsible for your students and their actions in the hotel. There will be a room curfew of 11:30 PM on Friday evening. Chaperones Responsibilities: Chaperones are required to transport their student representatives to and from YA Congress. Check students into hotel, using their names as they appear on the student form and the lodge that sponsored them to the congress. Never change rooms of students that the hotel has assigned; we need to know where everyone is located in hotel for security reasons and hall monitoring. Students must have separate room from chaperones, 2-students to a room. Required to remain with their student representatives during the Friday evening social and attend Saturday’s congress. Attendance will help you answer questions your students may ask you when organizing their Kids-Talks. You will also attend a chaperones meeting during Saturday’s congress. Students are not to be dropped off & picked up at a later time. They have the responsibility to not engage in the use of alcohol or tobacco products while interacting with the Youth Awareness students at all times. This includes the host meeting, any form of transportation that the lodge may provide for students, any KidsTalk that may be in your lodge, and from the time that you leave your lodge with students to attend the Student Congress until you return them safely home. NO smoking is allowed around the students. Absolutely no alcohol will be tolerated while acting as a chaperone from the time you leave your lodge until you return. PMA YA CONGRESS CHAPERONES MRR-2014 Youth Awareness Congress Tentative Schedule November 14th and 15th 2014 Windber FC # 349 November 21th and 22th 2014 Selinsgrove FC # 1173 Friday 3:00 pm until ? ~ Hotel Check-In 6:00 pm – 10:00 pm ~ Pizza and Hoagie Party with a DJ Saturday 7:00 am – 8:45 am ~ Breakfast & Registration 8:45 am – 9:00 am ~ Introductions & Group Breakout 9:00 am –12:00 pm ~ Group Rotations 12:00 pm – 1:00 pm ~ Lunch 1:00 pm –2:45 pm ~ Group Discussion & Video, workshop of kids-talks 2:45 pm – 3:00 pm ~ PMA Officers Comments 3:00 pm – 3:30 pm ~ Issue Moose Kids-Talk certificates, explain qualifications for MI Student Congress & Group photo. 3:30 pm ~ Depart for home. PMA YA Congress Schedule MRR-2014
© Copyright 2024