2019-20 Refuse To Use Registration

Please read each section carefully. Remember: Registration MUST be filled out in full, payment received, and an appropriate photo submitted. If there is a concern with registering, DO NOT submit another registration, email rtu@thecollaborative.us to confirm the next steps. *ALL youth participants AND parent/guardians MUST attend the entire Kick-off event, Sunday, September 8th, 3:00-5:00pm at Riley Rink. ** Leland & Gray students must attend the RTU Kick-Off on Monday, September 23rd at 6pm at L&G.

NOTE & Requirements:

Students and their parents or legal guardians MUST complete this form together. If you have questions, please call The Collaborative at 802-824-4200 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 Parent or Guardian to agree*

Student's information & agreement:

Student's FIRST name*

Student's LAST name*

Student's birth date*

Student's School*

Select

Student's Grade Level*

Select

Student's phone #*

Are you a BBA international student?*

Yes

Student's Email*

Student's address*

Student's Town / State / Zipcode*

Student Pledge:

I will refuse to use alcohol, tobacco and any other drugs, I will not misuse any over-the-counter or prescription drugs (i.e. diet pills, cold medicines, etc). I will support my friends in their choice to Refuse To Use alcohol, tobacco and other drugs. I will behave respectfully and responsibly at RTU events and while using my pass.I will not make any claims of illegal substances use in any printed material, public, speech and/or internet site. I will attend at least five of the scheduled substance use prevention education programs sponsored by my school or The Collaborative. By signing below I understand that I voluntarily give my word that I will honor this pledge and I will to follow the guidelines. If I cannot uphold this pledge, then my pass will be terminated.

Student Pledge agreement:*

I, student listed above, accept this pledge!

I do not accept this pledge.

Parent/Guardian information and agreement:

Parent/Guardian FIRST name*

Parent/Guardian LAST name*

Parent/Guardian work or cell phone*

Parent/Guardian home phone*

Parent/Guardian Email*

Parent/Guardian Address*

Parent's Town / State / Zip*

Photo use?*

I, the parent or guardian, 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, the parent or guardian, give consent to allow my student's name to be listed in publicity of the Refuse To Use program.

Yes, I give permission.

No permission.

RTU Parent/Guardian Pledge

I will support my student in their choice to be and remain substance free. I will notify the School Representative or The Collaborative if my student is unable to honor their pledge, and uses alcohol, tobacco or other drugs and therefore violates their pledge. i know that this will mean termination of my student's pass and that we will be provided resource referrals. I will provide or assist with my student's transportation to the scheduled substance abuse prevention education events. I will support my student by attending the Kick-Off event and Dialogue Night in January. In the event of a family scheduling conflict I will notify the Refuse The Use Representative at my student's school and attempt to make alternate arrangements.

Parent/Guardian Pledge agreement:*

I, Parent/Guardian listed above, accept this pledge.

I do not accept this pledge.

RTU Guidelines:

Both the student and his/her parent or legal guardian 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://www.thecollaborative.us/wp-content/uploads/2019/08/Refuse-To-Use-Program-Student-Guidelines-19-20.pdf Guidelines for parent/guardian: https://www.thecollaborative.us/wp-content/uploads/2019/08/Refuse-to-Use-ProgramParent-Guidelines19-20.pdf

Medical & Legal Releases*

Both the student and his/her parent or legal guardian 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*

Parent/Guardian agrees to Guidelines:*

As parent/guardian, I understand & agree to the Assumption of Risk and Release of Liability.

No agreement.

I am registering for a...*

Upload your photo for Stratton Pass

If you selected Stratton Mountain Ski/Ride Pass, then you MUST go to this link to fill out the required information and upload your photo, then return to this registration form to complete payment: https://strattonmountain.wufoo.com/forms/20192020-refuse-to-use-photo-upload/

Payment Options:

Select one option: 1. Mail Check, 2. Application, or 3. I'm a Leland & Gray student and will pay West RIver Valley Thrives, 4. Credit Card (via Website),.

I will mail a check of $50 to: The Collaborative, 91 VT Route 11, Londonderry VT 05148.

2. Mail a Check BEFORE September 9th, 2019.

I will fill out the scholarship application (click this link) https://www.thecollaborative.us/mark-weikert-scholarship/ and email it to rtu@thecollaborative.us

3. Scholarship Form to email BEFORE September 9th, 2019.

I'm a Leland & Gray student and will pay via West River Valley Thrives.

L&G Thrives

Yes, charge me $50 right now. Click on this link: https://www.thecollaborative.us/donate-now/

1. Credit Card payment via the website

Thank you!

A 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, call The Collaborative at 802-824-4200 to make sure that we have received your registration.

Send me a copy of my responses

Privacy Notice|Report Abuse