asl application form deadline: may 15

Parent/GuardianInformation__________________________________________

PrimaryParent/Guardian

Name:______________________________

Address:_________________________________________________

DateofBirth(mm/dd/yyyy):_____/_____/_______

EmailAddress:____________________________________________

HomePhoneNumber:______-______-__________

CellPhoneNumber:______-_______-__________

BusinessPhoneNumber:______-______-_________

SecondaryParent/Guardian

Name:______________________________

Address:_________________________________________________

DateofBirth(mm/dd/yyyy):_____/_____/_______

EmailAddress:____________________________________________

HomePhoneNumber:______-______-__________

CellPhoneNumber:______-_______-__________

BusinessPhoneNumber:______-______-_________

ASLApplicationFormDeadline:May15Submitto:[email protected]

ALS Application Form

DelegateInformation_________________________________________________

Name:___________________________________

PreferredName:________________

Gender(circleone):M/F

Height:_________

Weight:_________

HairColor:_________

EyeColor:_________

T-ShirtSize(circleone):Youth:Small/Medium/Large

Adult:Small/Medium/Large/XL/XXL

GradeEnteringintheFall:________

CurrentSchool:_____________________________________

SchoolEnteringintheFall(ifapplicable):__________________________________

SchoolType(circleone):Public/Private/Homeschool/Other

EthnicOrigin(Circleallthatapply):

• AmericanIndian/AlaskanNative

• Asian

• Black/AfricanAmerican

• Hawaiian/PacificIslander

• Hispanic/Latino

• White

• TwoormoreEthnicities

DateofBirth(mm/dd/yyyy):____/____/________

DelegateEmailAddress:___________________________

DelegateCellPhone:______-_______-__________

Pleaseindicateanyspecialinformationweshouldbeawareof(circleallthatapply):

• Medication

• MedicalCondition

• Life–ThreateningAllergy

• Allergy

• Asthma

• SpecialNeeds

• DietaryRestrictions

• Other

• None

HaveYouPreviouslyAttendedanMLWprogram?Yes/No

If“Yes”,whichprogramdidyouattend?_________________

HowdidyouhearaboutMLW?(circleone)

• School• Friends• MASC/StudentGovernment• LeadershipMaryland• Newspaper/Campguides• FormerDelegatesand/orStaff• MLWWebsite• Facebook• CampFair• Other

InterviewAvailability_________________________________________________Partofyourapplicationisaphoneinterview.Onthelinesnexttothedaysoftheweek,pleaselistthehoursthatyou,thedelegate,aretypicallyavailablefora15to20-minuteintervieweachday.Weekdayinterviewscantakeplaceintheeveningsandweekendinterviewscanhappenduringtheday.Pleaselistthewindowoftimethatyouaretypicallyavailable.

Monday Saturday Tuesday Sunday Wednesday Thursday Friday

SponsorshipInformation______________________________________________

Areyoureceivingasponsorship(meaningyourtuitionisbeingpartiallyorfullypaidforbysomeoneelse)fromyourschoolorotherorganization?(circleone)Yes/No

If“Yes”,pleasecompletetheinformationbelow:

SponsoredtoattendMLWby:______________________________

Amountofsponsorship:_______________

ContactNameforSponsorship:_____________________________

EmailforSponsorship:___________________________

PhoneforSponsorship:______-______-__________

MedicalQuestionnaire________________________________________________

DuetonewregulationswewillrequireallapplicantstocompleteandsubmitallMedicalforms(availablewiththerestofoursupplementalforms).Ifanyoftheformsdonotpertaintoyourchild,simplymarkN/Aontheformbeforesubmitting.

EmergencyContacts_____________________________________________________________

Pleaseindicatetwoalternativepeopletocontactifthefamilyisnotavailable.

PrimaryEmergencyContact:_________________________

RelationtoDelegate:________________

PrimaryPhone:______-______-__________

SecondaryPhone______-______-__________

SecondaryEmergencyContact:____________________________

RelationtoDelegate:__________________

PrimaryPhone:______-______-__________

SecondaryPhone:______-______-_________

HealthcareProviderContactInformation____________________________________________

Delegate'sPhysician:____________________________

PhysicianPhone:______-______-__________

PhysicianAddress:__________________________

Nameoffamilydentist/orthodontist:____________________

Dentist/OrthodontistPhone:______-______-__________

Dentist/OrthodontistAddress:______________________

HealthInformation______________________________________________________________

Doesyourchildhaveanymedicalconditions,psychologicalconditions,behavioralconditions,medications,dietaryrestrictions,allergies,orspecialneedsthatweneedtobeawareof?(circleone)

Yes/No

Pleaseexplainanymedicalconditions,psychologicalconditions,behavioralconditions,medications,dietaryrestrictions,allergies,orspecialneedsthatweneedtobeawareof:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Doesyourchildhaveanymedicationallergies?(circleone)Yes/No

Pleaseexplainanymedicationallergies:__________________________________________________________________________________________________________________________________________________________________________

Doesyourchildhaveanyfoodorotherallergies?(circleone)Yes/No

Pleaseexplainanyfoodorotherallergies:__________________________________________________________________________________________________________________________________________________________________________

Doesyourchildhavedietaryrestrictionsorotherneeds?(circleone)Yes/No

Pleaseexplainanydietaryrestrictionsorotherneeds:__________________________________________________________________________________________________________________________________________________________________________

ImmunizationInformation________________________________________________________

DoesthedelegateresidewithintheUnitedStates?(circleone)Yes/No


State/Territorywherethedelegateresides:__________________________

Isthedelegateexemptfromimmunizations?(circleone)Yes/No

If“Yes”,pleaselistthem:________________________________________________________

If“No”,pleaseprovidethecountryinwhichthedelegateresides:_______________________

PleaseNote:AllInternationalDelegatesarerequiredtocompleteandsubmitanInternationalimmunizationform,availablethroughthisURL:

https://phpa.health.maryland.gov/OIDEOR/IMMUN/Shared%20Documents/MDH_896_form.pdf

[email protected]

InsuranceInformation___________________________________________________________

Isthedelegatecoveredbymedical/hospitalinsurance?(circleone)Yes/No


InsuranceCompany:_______________________________________

InsurancePhoneNumber:______-______-__________

PolicyNumber:_______________________________

GroupNumber:_______________________________

IDNumber:__________________________________

If“No”,pleasereadandsignthesectiononthenextpage:

Thereisnomedicalinsuranceineffecttocovermyabove-namedson/daughterforanyillnesses,injuries,orotheradversehealthoutcomesthathe/shemayexperience.I,therefore,herebyagreetoassumedirectandcompletefinancialresponsibilityforanyandallmedicalcareofanykindthatmyabove-mentionedson/daughterreceiveswhileattendingMarylandLeadershipWorkshops,Inc.’s2018summerresidentialleadershipprograms.

Further,IherebyagreetoreimburseMarylandLeadershipWorkshops,Inc.foranyandallcosts,medicalexpenses,andothersumsthatMarylandLeadershipWorkshops,Inc.advancesthatrelatetothemedicaltreatmentofmyson/daughterwhilehe/sheisattendingMarylandLeadershipWorkshops,Inc.’s2018summerprograms.

____________________________________________________________________

Parent/LegalGuardianSignature PrintedName Date

ScholarshipInformation_______________________________________________

Ifapplyingforascholarshipfor2018,pleasecontactmatt@leadershipmd.orgtoobtainascholarshipapplication.

Parent/LegalGuardianEmploymentInformation__________________________

PrimaryParent/Guardianemployer:__________________________________________

SecondaryParent/Guardianemployer:_____________________________________________

BehavioralQuestionnaire_____________________________________________

ThesectionprovidedonthefollowingpageasksforinformationthatisimportantforustoensureyourchildhasasuccessfulweekatMLW.YouranswerstothesequestionsARENOTafactorintheacceptanceofyourchildintoourprogram.Pleasebehonestandforthrightsothatourstaffcanbestpreparetoworkwithyourchild.

Ifyourchildhasamentalorphysicalhealthdiagnosisorissue,howdoesitaffectthemonaday-to-daybasis?Whatdoweneedtoknow?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Hasyourchildeverbeenhospitalizedduetobehavioralissues?Ifyes,pleaseexplain:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Hasyourchildeverbeenawayfromhomewithoutfamilyforaweek?(circleone)Yes/No

Doesyourchildrelateeasilytoothers,oristhatoftenachallenge?

_____________________________________________________________________________________

Doesyourchildenjoyparticipatinginlargegroupactivities?Oraretheyhappierbeingalone/insmallgroups?

_____________________________________________________________________________________

Whenyourchildisfrustrated,angry,upsetorsad,howdotheyhandletheseemotions?

__________________________________________________________________________________________________________________________________________________________________________

Whattechniquesaresuccessfulforhandlinginappropriatebehaviorsbyyourchild,shouldthosebehaviorsarise?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describeyourchild'spersonality.Whatdotheyenjoy/notenjoydoing?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CustodialInformation________________________________________________

Doesanyoneotherthantheadultslistedinthisapplicationhavepermissiontopickyourchildupfromcamp?(oldersiblings,extendedfamilymembers,friends,etc.)

(circleone)Yes/No

If“Yes”,pleaseenterthenamesandphonenumbersofupto3authorizedpersonsbelow:

AuthorizedPerson1Name:_______________________________________

AuthorizedPerson1PhoneNumber:______-______-__________





Isthereanissueovercustodyofthedelegate?(circleone)Yes/No

If“Yes”,pleaseexplaintheissueovercustody.Beasthoroughaspossiblesothereisnoconfusionwhileyourchildisinourcare:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Waivers____________________________________________________________Parents/Guardians-Pleasereadthisformandreviewwithyourchild.

AttendanceandRefundPoliciesThefollowingrefundscheduleappliesfordelegateswhocanceltheirregistration.·CancellationsbeforeMay1st,willreceivea$500refund.·CancellationsbetweenMay1standJune1st,willreceivea$300refund.·CancellationsafterJune1stcannotberefunded.·RefundswillbeissuedbySeptember30th.Allnecessaryitemsforacompleteapplication,includingsignedmedicalforms,mustbereceivedpriortoMay15th.Areservedspaceintheprogrammaybeforfeitedinordertomakeroomforthedelegateswhoareonthewaitinglistifmaterialisnotreceivedbythedeadline.StudentsparticipatinginMLW’ssummerprogramsmustparticipateintheentireweek-longresidentialexperience.Studentswillnotbepermittedtoarriveattheprogramlateordepartearly.Unfortunately,refundscannotbemadetostudentswho,forunexpectedhealthorotherreasons,mustleavetheprogramearly.MLWreservestherighttoexpelwithoutrefundanystudentwhoviolatesMLW’sRulesandExpectations,violatesMarylandStatelaw,orforothercause.

PermissiontoApplyandAttendIherebygrantpermissionformychildtoapplytoandparticipateinthisprogram.Iacceptandassumeanyandallrisksassociatedwithhis/herattendanceandparticipationintheprogramanditsactivities.Iunderstandthatmychildshouldnotattendthecampifhe/sheisnothealthy.Iunderstandthatmychildmustabidebyprogrampoliciesandtheinstructionsofprogramstaff.Ipermitmychildandhis/herimagetobeinvolvedinactivitiesandmediaeventsthataredesignedtopromotethebenefitsofMarylandLeadershipWorkshops,Inc.,includingbutnotlimitedtophotographs,videotapes,postingimagesontheMLWwebsite,facebookpage,Twitter,Instagramandothersocialmedia,newslettersandpressreleases.Additionally,IherebygrantpermissionforMLWtosharetheschoolnameandemailaddressofmychildwithotherparticipantsinMLWprograms,localschoolsystempersonnel,LeadershipMaryland,andlocalcommunityleadershipassociations.Knowingthesefacts,I,formyself,mychildattendingtheprogram,andanyoneelsewhomightclaimonmyormychild’sbehalf,herebyagreethatMLWisnotresponsibleforlostorstolenitems,accidents,injuries,and/ormedicalordentalexpensesarisingfrommychild’sparticipationintheprogramand,accordingly,Icovenantnottosue,andwaive,releaseanddischargeMLWandanyoneworkingontheirbehalffromanyandallclaimsofliabilityorexpensesofanykindornaturewhatsoeverarisingoutoforrelatingtomychild’sparticipationintheprogram.Ihavecarefullyreadalloftheinformationinthisapplicationformandagreetoallconditions.

ExpectationsofDelegateRESPECTRespectforoneanotherisofprimaryimportanceinorderforalldelegatesandstaffmemberstolearnandgrowthroughouttheweek.Treatotherswithrespectfulbehaviorsothatyoumayexpectthesameinreturn.Respectfulbehaviorincludes:·RespectrequestsmadebyMLWstaffmembersandcampusemployees.·Avoidtheuseofprofanity/obscenelanguage.·RespecttheprivacyofMLWparticipantsandothergroupswhomaybeusingthecampus.·Avoidtouchingofotherpeopleandtheirbelongings(thisincludesfightsandtheft).·Respectallideasandbeliefsandavoidtheuseofderogatorycommentstowardsothers.ATTENDANCEItisexpectedthatyouwillattendallscheduledactivities.Wehavemanyfunandchallengingactivitiesforyouandexpectthatyouwillbeapartofeachone.Eatingthreebalancedmealsaday,drinkingplentyofliquids,andgettingenoughsleepwillensurethatattendingallactivitieswillbenoproblem.Incaseofanemergencyoranycircumstancepreventingparticipationinactivities,notifyastaffmemberimmediately!

RulesandProcedurestoFollowforaSAFEandFUNweekINANDAROUNDDORMITORIESTherewillbenoguysongirls’hallsandnogirlsonguys’hallsunlessapprovedinadvanceforanofficialactivity.Thisincludesstairwellsthatleadfromsuchhalls,whicharelabeled“offlimits.”Commonareasareopentoalldelegates.Nooutsidevisitorsarepermittedatanytimeduringtheweekwithoutpriorpermissionfromtheprogramdirector.Intheeventofafire,pullthefirealarmandexitthebuildingquickly,knockingonthedoorsthatyoupass.Checkinwithyourassignedstaffmemberatthedesignatedmeetinglocation.Intheeventofanothertypeofemergency,contactthestaffmemberwhoisonDormDuty.His/hernamewillbepostedonyourhalleachday.Donotpropopenoutsidedoorsatanytime.

CHECK-INANDLIGHTSOUTCheck-inwilloccureverynightatthetimeindicatedintheguidebookyoureceiveatregistration.Youmustcheckinwithastaffmemberfromyourhallbythestatedtime.Wewillgiveyoutimetogetreadyforbed,andwewillusuallyscheduleahallmeetingaftercheck-in.LightsmustbeTURNEDOFFatthetimedesignatedinyourguidebook.Althoughyoumaybeaccustomedtostayingupabitlater,rememberthatthisweekisveryactiveanddemandsyourfullenergyeveryday.Youwillneedyoursleeptofullyparticipateinallactivities.AROUNDTHECAMPUSAtregistration,youwillreceiveanMLWbuttonwithyournameonit.Thisbuttonmustbewornatalltimesunless,ofcourse,youareintheshowerorsleeping.Youmustalsowearshoesatalltimesexceptwhenshoweringandsleeping(althoughyoumaywanttowearshowershoes).YoumayNOTleavecampusatanytimeorforanyreason.Ifyouareuncertainofcampusboundaries,askastaffmember.Commercialpropertieslocatednearthecampusarenotpartofthecampus.Ifyouhaveforgottenanecessityitem,givetheofficestaffmoneyandawrittendescriptionoftheitem,andtheywillsecureitforyou.Ifyouaredrivingyourselftotheprogram,pleaseinformtheMLWExecutiveDirectorAnitaAndersonatanita@leadershipmd.orgsothatparkingandotherarrangementscanbemadeforyou.DoNOTwalkaloneanywhere—alwaystakeabuddywithyou.TOBACCO,ALCOHOL,ANDOTHERDRUGSThepossessionand/oruseofdrugs,alcohol,andtobaccoisabsolutelyforbiddenatalltimesduringtheweek.Nooverthecounterorprescriptionmedicationisallowedindormrooms.AllmedicationistobeturnedintothehealthconsultantatregistrationandwillbeavailablebycomingtotheMLWonsiteoffice.Onlydelegateswithformssignedbyahealthpractitionerwillbeallowedtotakeoverthecounterorprescriptionmedication.

INAPPROPRIATEBEHAVIORANDCONSEQUENCESTheseexpectationsareintendedtoallowalldelegatesandstaffmemberstohaveasafeandsuccessfulweek.Anybehaviordescribedinthisdocumentoratthediscretionofastaffmemberthatthreatensorjeopardizesthesafetyofotherpersonsortheirenjoymentoftheprogramwillnotbetolerated.TheMLWdirectorsandstaffmaytakeanyofthefollowingactionsasaconsequencefordelegateswhodonotmeettheexpectationsoutlinedabove:·Aconferencewiththedelegateandastaffmember.·Aconferencewiththedelegateandaprogramdirector.·Aphonecallhomeinformingaparent/guardianoftheincident.·Adelegate-writtenletterofapologytotheoffendedparty.·Thewithholdingofparticipationinsocialactivities.·Removalfromtheprogram(aparent/guardianwillberequestedtopickupthestudent).

MEDICATIONANDHEALTHCARERELEASE

PARENTALRELEASEANDACKNOWLEDGMENT:Igivepermissiontoauthorizedpersonneltocarryoutsuchemergencydiagnosticandtherapeuticproceduresasmaybenecessaryformyson/daughter,andalsopermitsuchprocedurestobecarriedoutat,andby,localhospital(s)intheeventthatmyson/daughteristakenthereforemergencycare.Iagreetothereleaseofanyrecordsnecessaryforinsurancepurposes.IgrantpermissiontoMarylandLeadershipWorkshops,Inc.toarrangeanyrelatedtransportationnecessarytocareformychild.Iunderstandthatanymedicalexpenseswillbedirectlybilledtomyinsurancecompanyorme.Icertifythatallmedicalandhealthhistoryinformationprovidedinthisapplicationiscompleteandaccuratetothebestofmyknowledge.IherebyreleaseandholdharmlessMarylandLeadershipWorkshops,Inc.anditsagents,servants,contractorsandemployeesfromanyandallliabilitythatmayresultfrommedicalcareofmyson/daughter.Ifurthercertify,thatunlessindicatedontheDelegateMedicationForm,myson/daughteriscapableofself-administeringanyprescribedmedication(s)andIassumeallresponsibilityandliabilitystemmingfrommydecisiontohavemychildself-administermedication(s).Intheeventthatthereisnomedicalinsuranceineffecttocovermyabove-namedson/daughterforanyillnesses,injuries,orotheradversehealthoutcomesthathe/shemayexperience.Iherebyagreetoassumedirectandcompletefinancialresponsibilityforanyandallmedicalcareofanykindthatmyabove-mentionedson/daughterreceiveswhileattendingMarylandLeadershipWorkshops,Inc.’s2018summerresidentialleadershipprograms.Further,IherebyagreetoreimburseMarylandLeadershipWorkshops,Inc.foranyandallcosts,medicalexpenses,andothersumsthatMarylandLeadershipWorkshops,Inc.advancesthatrelatetothemedicaltreatmentofmyson/daughterwhilehe/sheisattendingMarylandLeadershipWorkshops,Inc.’s2018summerprograms.

MychildandIhavereadandunderstandthepolicies,expectations,andrulesstatedaboveandacknowledgethatviolationofanyoftheserulesmayresultindismissal.

DelegateFirstandLastName:___________________________________________________________

DelegateSignature:__________________________________________________Date:______________

Parent/GuardianFirstandLastName:______________________________________________________

Parent/GuardianSignature:___________________________________________Date:______________

MLWPACKINGLIST

• Enoughcomfortable,weatherappropriateclothingfortheweek.Yourclothesfortheweekshouldbeschool-appropriate;ifyouwouldn’tbeallowedtowearitatschool,pleasedonotbringittoMLW.MLWstaffanddelegatesallwearcasual,comfortableclothing.It’sagoodideatobringshorts,t-shirts,jeans,sneakers,andasweatshirt,aswe’llbedoingactivitiesbothinsidetheairconditioningandoutsideinthesummerheat.

• Therewillbeavarietyshow/showcasethatdelegateswillplanandimplement.Pleasebringanyinstruments,equipment,oranythingelsethatwillhelpyoushareyourtalentwiththerestoftheMLWcommunity,ifyoulike.

• Sheetsforanextra-longtwinbed(and/orasleepingbag)andablanket(thedormsareairconditionedsoitcangetcold)

• Pillow

• Towels–bathtowel,handtowel,washcloth

• Toiletries(don’tforgetatoothbrush,toothpaste,handsoap,showersoap,anddeodorant)

• ShowerShoes

• Arainjacket/umbrella

• AlarmClock

• Pensorpencils

• Reusablewaterbottle

• Smallbackpackordrawstringbagtocarryguidebook,pens,etc.

• Athleticequipmentforrecreationtime

• Lightsnacksanddrinksforevenings(optional–MLWwillalsoprovide).

• Anoutfit(shorts,tshirt,oldshoes)thatcangetwetanddirty

• Onebusinesscasualoutfit

• SunscreenandBugSpray,aswedoactivitiesoutdoorsduringthedayanintheevenings.

TobecompletedbyApplicant:Delegate(Student)Name: RecommenderName: TobecompletedbyRecommender:RecommenderAddress: City/State/Zip: Phone: Emailaddress: RelationshiptoStudent: LengthofTimeYouHaveKnownStudent:

Pleaserateapplicantinthefollowingareasusingascalefrom1-5

(1=notatallstronginthisarea,2=lowinthisarea,3=averageinthisarea,4=goodinthisarea,5=very

stronginthisarea)

Abilitytoworkwithothers 1 2 3 4 5

Self-awareness 1 2 3 4 5

Communicationskills 1 2 3 4 5

Abilitytogiveandreceivefeedback 1 2 3 4 5

Abilitytoempowerandmotivateothers 1 2 3 4 5

ALSApplicationRecommendationFormAlsoavailableonlineatgoo.gl/c8eFxRTotheApplicant:IfyouhaveneverattendedanMLWprogram,pleasegivethisformtobecompletedbysomeonewhocanwriteaboutyourleadershippotential.Besuretocompleteyourinformationbeforegivingtheformtoyourrecommender.Itisalsoagoodideatoprovideaself-addressed,stampedenvelope.TotheRecommender:Pleaseanswerthequestionsbelowbasedonyourinteractionwiththeapplicant.Ifaccepted,thisstudentwillspendaweekwithstudentleadersfromtheMid-Atlanticregion,developinghis/herleadershipskills,implementingaproject,andsettinggoalsforactionathome.Formoreinformation,visitwww.mlw.org.

Pleaserespondtothefollowingquestionsinordertogiveusadditionalinsightontheapplicant.Ifyou

wouldprefer,youmayuseanadditionalsheetofpapertorecordyouranswers.

1. Whataretheapplicant’sstrengthsandweaknesses?

2. Howdoestheapplicantdemonstrateleadershippotential?

3. HowwouldtheMLWcommunitybeenrichedbytheapplicant’sparticipation?

4. Othercomments:

______________________________________________________ ____________

Signature Date

Pleasereturnthisformdirectlyto:MLW,c/oLeadershipMD.,134HolidayCourt,Suite318,Annapolis,

MD21401orFax:410-841-2104;[email protected]

DelegateFirstandLastName:

__________________________________________________________________________________

Date:___/____/_____

1. WhydoyouwanttoattendALS?

2. Usingyourownwords,howwouldyoubestdefineordescribe“leadership”?Thinkaboutcharacteristics,skills,qualities,and/orbehaviorsleaderspossessincreatingyourdefinition/description.

3. Usingyourdefinition/descriptionofleadershipfromquestion2,tellusaboutoneinstanceinwhichyoudemonstratedleadership.Describetheskillsandqualitiesyouused,thechallengesyoufaced,andhowyouovercamethosechallenges.

4. ImaginethatyouweretheleaderofacommitteethatwasputinchargeoffixingaseriousissuefacinghighschoolstudentsinMaryland.Whatseriousissuewouldyouchoose?Whywouldyouchoosethisissue?Whatspecificallycouldyourcommitteedotohelp?

5. Describeyourself.Whatareyourinterestsand/ortalents?Whattypesofactivitiesareyouinvolvedwith?Whatdoyouliketodoinyoursparetime?

6. ALSisalearningexperiencedesignedtohelpyougrow.WhataspectofyourleadershippotentialwouldyouliketoworkonwhileatALS?WhatskillswouldyouliketodeveloporpolishwhilehereatALS?

7. WhatisonepieceofadvicethatyouhavefortheupcomingALSstaffaswedesignourprogram?Considerwhattopicsoractivitiesyouwouldlikeustoinclude,howyou’dlikeustoschedulethedays,thingsyouwantustokeepthesameasotherMLWprogramsandthingsyou’dliketochangefromotherMLWprograms.

8. PleaselisttheyearsthatyouhavepreviouslyattendedMLW,theprogramandgroupthatyouwereinforthoseyears,themainideaofyourgroup’sproject,andthemajorconceptsorskillsthatyoutookoutofeachyear.

ALSApplicationStudentLeadershipInsightsQuestionnairePleaseanswerthefollowingquestionsonaseparatesheetofpaperincompletesentences.Youmayeithertypeorwriteneatlyinblueorblackink.Pleaseputyourfullnameatthetopofeachpage.Applicantanswersareusuallyaboutahalf-pagetofullpageinlength,butpleasefeelfreetouseasmuchspaceasyouwouldlike.TheanswerstothesequestionsareafactorusedintheprocesstodeterminewhetheryouareacceptedtoALS.Ifyouareaccepted,thestaffwilluseyouranswerstodesignaprogramtomeetyourneeds.

MEDICATION ADMINISTRATION AUTHORIZATION FORM for Youth Camps in Maryland

Department of Health & Mental Hygiene (DHMH) Center for Healthy Homes and Community Services (CHHCS) (410) 767-8417 Toll Free 1-877-4MD-DHMH ext. 8417

This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the camper to self-administer medication. A new medication administration form must be completed at the beginning of each camp season, for each medication, and each time there is a change in dosage or time of administration of a medication.

• Prescription medication must be in a container labeled by the pharmacist or prescriber. • Nonprescription medication must be in the original container with the instructions for use. Nonprescription medication includes

vitamins, homeopathic, and herbal medicines. • An authorized individual must bring the medication to the camp and give the medication to an adult staff member.

I. PRESCRIBER’S AUTHORIZATION 1. CHILD’S NAME 2. DATE OF BIRTH ___/___/______

MonthDay Year

3. CONDITION FOR WHICH MEDICATION IS BEING ADMINISTERED: 4. EMERGENCY MEDICATION

[ ] YES -If yes, see Section III below. [ ] NO 5. MEDICATION NAME 6. DOSE 7. ROUTE 8. TIME/FREQUENCY OF ADMINISTRATION 9. IF PRN, FREQUENCY 10. IF PRN, FOR WHAT SYMPTOMS 11. KNOWN SIDE EFFECTS SPECIFIC TO CHILD 12. MEDICATION SHALL BE ADMINISTERED 12a. FROM 12b. TO during the year in which this form is dated in 14b below unless more restrictive dates ___/___/______ ___/___/______ are specified in 12a and 12b. This authorization is NOT TO EXCEED 1 YEAR. MonthDay Year Month Day Year

13. PRESCRIBER’S NAME/TITLE This space may be used for the Prescriber’s Address Stamp TELEPHONE FAX ADDRESS CITY STATE ZIPCODE 14a. PRESCRIBER’S SIGNATURE (Parent/guardian cannot sign here) 14b. DATE (ORIGINAL SIGNATURE OR SIGNATURE STAMP ONLY)

II. PARENT/GUARDIAN AUTHORIZATION I request the authorized youth camp operator, staff member or volunteer to administer the medication or supervise the camper in self-administration as prescribed by the above authorized prescriber. I certify that I have legal authority to consent to medical treatment for the child named above, including the administration of medication at the facility. I understand that at the end of the authorized period, an authorized individual, as listed in 15c below, which may include the child, must pick up the medication, otherwise it will be discarded. I authorize camp personnel and the authorized prescriber indicated on this form to communicate in compliance with HIPAA. 15a. PARENT/GUARDIAN SIGNATURE 15b. DATE 15C. INDIVIDUAL(S) AUTHORIZED TO PICK UP MEDICATION

15d. HOME PHONE # 15e. CELL PHONE # 15f. WORK PHONE #

III. AUTHORIZATION FOR SELF-ADMINISTRATION / SELF-CARRY

This section should only be completed if this medication is approved for self-administration. Self-carry is only permitted for emergency medications such as inhalers and epinephrine. Both the prescriber and the parent/guardian must consent to self-administration below. However, youth camp operators are not required to permit self-administration or self-carry. I authorize self-administration of the above listed medication for the child named above under the supervision of the youth camp operator, a designated staff member or volunteer. If indicated below, the child named above may self-carry emergency medication.

16a. PRESCRIBER’S SIGNATURE 16b. SELF-CARRY EMERGENCY MEDICATION (Check One) 16c. DATE authorizing self-administration [ ] YES [ ] NO [ ] N/A - Not emergency medication

17a. PARENT/GUARDIAN’S SIGNATURE 17b. SELF-CARRY EMERGENCY MEDICATION (Check One) 17c. DATE authorizing self-administration [ ] YES [ ] NO [ ] N/A - Not emergency medication

DHMH-4758 (01/2017) KEEP FOR 3 YEARS Page 1 of 1

MLWDELEGATEMEDICALFORM–OvertheCounterMedicationForm

ThedelegatewillonlybeallowedtohaveOTCmedicineandself-administermedicationonanasneededbasisifthisformisfilledoutcorrectlyandinourfiles.Therefore,pleasefillthisformoutcompletely,signatthebottom,andreturntoMLW(oruploadtoyouronlineaccount)byMay15th.THESEMEDICATIONSWILLBESTOREDINTHEMLWOFFICE,anddelegatescanrequesttotakethemasneeded.

Program: ALS MSEL SHW Journey DelegateName:

Delegate’sAge:___________ Delegate’sWeight:_______________

DrugNameGenericmaybesubstitutedforbrandname

Route/Howitistaken Dosage&Schedule(perlabelinstructionsbyage/weight,unlessotherwiseindicated)

Indications Parent/Guardian/HealthCareProviderPermission(circleone)

Thingstobeawareofwhenonthismedication/Comments

Tylenol(orgeneric)

PO(chewable,elixir,ortabs)PR(suppository)

PerlabelInstructions

PainorFever YesorNo

Ibuprofen PO(chewabletabs,suspension,ortablets)


PainorFever YesorNo

Robitussin(orgeneric)

PO(syrup) PerlabelInstructions

Cough YesorNo

Pepto-Bismol(orgeneric)

PO(liquidorchewabletabs)


Upsetstomach,Diarrhea

YesorNo

Kaopectate(orgeneric)

PO(liquidortab) PerlabelInstructions

Diarrhea YesorNo

Children’sMylanta(orgeneric)

PO(chewable) PerlabelInstructions

Upsetstomach YesorNo

Sudafed(orgeneric)

PO(tabsorliquid) PerlabelInstructions

Nasalcongestion,Eustachiantubecongestion

YesorNo

Chlorpheniramine PO(chewabletabs,suspension,ortabs)


Seasonalallergysymptoms

YesorNo

Zyrtec/Claritin PO PerlabelInstructions

Seasonalallergysymptoms

YesorNo

Dramamine/Bonine(orgeneric)

PO(chewable/regulartabs)


MotionSickness YesorNo

Dimetapp(orgeneric)

PO(elixirortabs) PerlabelInstructions

Nasalcongestion,Seasonallergy

YesorNo

Benadryl(orgeneric)

PO(elixir,chewable,tab,orpills);topicalointment


Allergicreactions(hives,insectbite,allergies)

YesorNo

Antibioticointment Topical PerlabelInstructions

Superficialcuts/abrasions

YesorNo

HydrocortisoneCream

Topical PerlabelInstructions

Allergicreactions,contactdermatitis,insectbite

YesorNo

CalamineLotion Topical PerlabelInstructions

Allergicreaction(insectbite,hives)

YesorNo

Vitaminsand/orSupplements*

PO PerlabelInstructions

YesorNo

I,_______________________(parent/guardianname),givepermissionformychildtotakethemedicationslisted“YES”aboveandmychildhastakenathomeatleast1doseofthemedication(s)listedas“YES”above.IdoNOTwantmychildtotakethefollowingmedications: ParentorLegalGuardian’sSignature Date