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