L&G 2021-22 Refuse To Use Registration

Please read each section carefully. Remember: Registration MUST be filled out in full, payment received, and an appropriate photo submitted by 10/10/2021. If there is a concern with registering, DO NOT submit another registration, email natalie@thecollaborative.us to confirm the next steps. Please read this entire document carefully as it outlines instructions for this year and Covid-19 related policies: https://docs.google.com/document/d/1b0UaUJXyeA9IUzPAiCjdrUXD_N6d1cR4H19YegT477U/edit

NOTE & Requirements:

Students and their Caring Adults MUST complete this form together. If you have questions, please contact Natalie@thecollaborative.us for assistance.

By clicking below, I understand my student must follow the guidelines and policies of the RTU program. I realize my student must EARN and MAINTAIN their pass. Passes can be suspended or terminated at anytime for non-compliance.

For Caring Adult to agree*

Student's FIRST name*

Student's LAST name*

Student's birth date*

Name of student's school*

Select

Student's Grade Level*

Select

Student's phone #*

Student's address*

Student's Town / State / Zipcode*

Pledge Guidance:

Pledge: (noun) a solemn promise or agreement - an intention I set for myself to help guide my decision-making for the present and future. Pledges are meant to be transformational and inspire involvement and investment. To that end: The policies and transactional information and expectations of the RTU program can be found on our website. These outline the guidelines of the program as required by all involved parties.

Student Pledge 2021-22:

I understand that being a part of the Refuse to Use asset building program is a choice and one that I embark upon with an open mind and heart. I will participate knowing that my life has meaning and that what I say, think, and do has an impact on the world around me. I will do my very best to engage fully in the RTU program and to attempt to use the skills I have learned in a practical way in my own life. I will do my very best to reach out for help and resources from the community that supports me if I need guidance in making healthier choices.

Student Pledge agreement:*

I, student listed above, accept this pledge!

I do not accept this pledge.

Full name of Caring Adult assisting with registration and payment:*

Caring adults are not always parents or guardians but may be a grandparent, family friend, etc.

Caring Adult's Email*

Caring Adult's Phone #*

Student Questions:

What are some coping mechanisms that you use to get through tough situations?*

What do you think are some factors that may contribute to your peers partaking in substance misuse?*

Contact or Caring Adult's information and agreement:

Contact's FIRST name*

This (Emergency) Contact Person may the same or be a different family member, guardian from above Caring Adult.

Contact's LAST name*

Contact's work or cell phone*

Contact's home phone*

Contact's Email*

Contact's Address*

Contact's Town / State / Zip*

Photo use?*

I, the caring adult, give consent to allow my student's picture to be used in publicity of the Refuse to Use program. (Photos and names will not be used together without a specific request at that time.)

Yes, I give permission.

No permission.

Publicity use?*

I give my consent to allow my student's name and/or responses (photos, written work, songs, creative projects, etc.) contained therein for publicity for The Collaborative.

Yes, I give permission.

No permission.

Caring Adult's Pledge 2021-22:

I will support our youth and encourage them in their decision to make healthy choices.

Caring Adult Pledge agreement:*

I, Caring Adult listed above, accept this pledge.

I do not accept this pledge.

Caring Adult Questions:

What are some of the factors that may contribute to youth misusing substances?*

What do you hope for your scholar(s) to learn from this year's programming?*

RTU Guidelines:

Both the student and his/her parent or caring adult must agree to each of the provisions below. Click, read and accept the RTU Guidelines to participate in the program. (Opens in a new window, read the agreement, then close the window.) Guidelines for student: https://docs.google.com/document/d/1ijJYF4zlKOvsayA77mA_6NQE2bQcA7P7-Ozo2o4vNnk/edit?usp=sharing Guidelines for caring adult: https://docs.google.com/document/d/1-S5RVzfcc3aldh2C5cgvA04X48NrLxpM-9C3j-Z8D5M/edit?usp=sharing

Medical & Legal Releases*

Both the student and their caring adult must agree to medical and legal release for Stratton Mountain Resort. Click, read and accept the Stratton Mountain Medical Release. (Opens in a new window, read the agreement, then close the window.) https://www.thecollaborative.us/wp-content/uploads/2017/08/AssumptionOfRisk.pdf

I, the parent/guardian, agree to the terms of Stratton Mountain Medical Release.

I do not agree to these terms.

I, the student, have read and accept this agreement.

Student agrees*

Risk and Release of Liability:

The Collaborative is a Vermont non-profit corporation organized for the purpose of promoting, developing and implementing substance use education and prevention projects in the greater Londonderry and Manchester area. This release of liability form relates to the Refuse To Use program. By signing this form, I agree to assume any risk of injury to me, my child or ward, or to my or his / her property while participating in The Collaborative's Refuse To Use Program. I agree that if any loss or injury occurs to me, my child or ward, or our property, that I will release from liability and make no claim against The Collaborative, its agents, representatives, employees or volunteers. If there is any claim against The Collaborative relating to injury to any person or property caused by me, my child or ward, I agree to indemnify and hold harmless The Collaborative, its agents, representatives, employees and volunteers harmless from any and all liability, claim, suits, expenses, and attorney's fees. This assumption of Risk and Release of Liability agreement is made by me and on behalf of my child or ward, our heirs, executors and assigns.

Risk & Release of Liability*

Caring adult agrees to Guidelines:*

As a caring adult, I understand & agree to the Assumption of Risk and Release of Liability.

No agreement.

I am registering for a...*

Riley Rink Pass

Viking Nordic Pass

Stratton Mountain Pass

Magic Mountain Pass

No pass: I am participating in the program by donation or free of cost without a Ski Pass incentive.

Stratton Pass Pictures:

If you have a picture with Stratton already, they will use the previous year picture unless otherwise indicated. If you would like a new picture, or need to upload a picture for a STRATTON PASS, please email guest services at Stratton Mountain at guestservices@stratton.com with the following information: Full Name, Grade, School Attending.

Payment must be received by October 10th, 2020:

Select ONE OPITON to check box, follow payment directions: 1. Mail a Check, or use 2. Venmo, or 3. charge Credit Card.

I will mail a check of $35 to: The Collaborative, 91 VT Route 11, Londonderry VT 05148. Please put "RTU" & student's name in the memo line on the check.

1. Mail a Check. Must be received by October 10th.

Use the Venmo app and send $35 right now to The Collaborative's Jackie Borella: @thecollaborativevt and put "RTU" and the student's name in the memo line.

2. Venmo payment. Remember to finish/submit this registration form.

Yes, charge me $35 right now. Click on this link: https://www.thecollaborative.us/donate-now/

3. Credit Card payment via The Collaborative website. Remember to finish/submit this registration form.

I've completed the Scholarship Application (link below) and scanned/emailed the application to natalie@thecollaborative.us by 10/10/21. https://docs.google.com/document/d/1MSlszj9g7mR6l-iIyR3Nye5-k1s72oey4CwgtJABe40/edit

4. Scholarship Application link. Remember to finish/submit this registration form.

Thank you and next steps!

A registration confirmation email will be sent, please check your junk mail if it is not in your inbox within 24 hours. If no email is received, then email natalie@thecollaborative.us to make sure that we have received your registration.

Send me a copy of my responses

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