Youth Application Form

Youth Information

This application is designed to be filled out by the youth and guardian together. It must be signed by a legal guardian.

SF Prefill Fields - Do Not Modify

Term Year

Position Location

Position Type

Youth Information

Legal First Name

Last Name

Preferred First Name

Email (Youth Participant's)

Leave blank if you don't have the youth's email! Do not enter a parent/guardian email.

Phone

Enter the youth's cell number. If they don't have a cell phone, enter their home phone.

Birthdate

Mailing Address

City

State

Postal Code

Highest Grade Completed at Program Start Date

Where do you attend school?

T-Shirt Size (Adult Unisex)

How did you hear about this specific position?

Social Media

Name of Person, Site, Listserv, Newspaper, School or University

Racial Identity

Ethnicity

Gender

Pronouns (select all that apply)

She/Her/HersHe/Him/HisThey/Them/Theirs

Application Information

We do our best to accommodate your branch preference. However, we cannot guarantee openings in all branches.

	Yes	No
Are you willing and able to serve in another branch?
Are you willing and able to serve in another session?

Do you qualify for free or reduced lunches at school

* This information is kept anonymous and only used as part of our efforts to raise more funds for our youth programming at MCC.

Is your primary residence in Montana?

What most excites you about the opportunity to participate in an expedition?

Have you ever spent time away from home in a camping environment before? Do you have any concerns about being isolated (with no phone) in the field for the duration of the expedition you are applying for? (3-11 days)

Do you have any concerns about working in remote field environments (with no phone) for the duration of your work day?

Legal Guardian/Emergency Contact

List at least two separate contacts with two different phone numbers. MCC will make every effort to call contacts in the order listed. Emails may be used to provide information about MCC programs.

Legal Guardian 1 Information

First Name

Last Name

Email

Do not enter the same email as the youth

Primary Phone

Primary Phone Type

Secondary Phone

Secondary Phone Type

	Yes	No
Is this person in the same household/address as the youth

Address

City

State

Postal Code

Relationship

Legal Guardian 2 Information

First Name

Last Name

Email

Do not enter the same email as the youth

Primary Phone

Primary Phone Type

Work Phone

Secondary Phone Type

	Yes	No
Is this person in the same household/address as the youth

Address

City

State

Postal Code

Relationship

Emergency Contact Information (Must be Different From Above)

Please provide an alternative Emergency Contact, in addition to the Parent/Guardian

First Name

Last Name

Email

Mobile Phone

Home Phone

Work Phone

	Yes	No
Is this contact in the same household/address as the youth

Address

City

State

Postal Code

Relationship

Optional- Please list any individuals who are authorized to pick-up your child on return day. Authorized Pick-up person will need to bring Photo ID on day of pick-up so MCC staff can confirm.

Health History Introduction

Montana Conservation Corps wants your child to have a successful and positive experience this summer. Thank you in advance for sharing the most up to date medical information and verifying your child can perform the tasks required for participation listed below.

Each year youth participants with a variety of medical and mental health backgrounds have successfully participated in MCC programs. If your child has a disability, we strongly encourage you to contact MCC staff so that we can discuss reasonable accommodations prior to the start of the program.

Any enrollment acceptance is conditional upon completion of the health history questions on the following pages. Youth participating in MCC programs must be able to:

· Walk on uneven, outdoor terrain and negotiate natural obstacles, such as hills, streams, and boulders.

· Live in a rustic location not always accessible by vehicles.

· Sleep in their own tent, near other teens and adult leaders within an established campground area.

· Participants must remain in their tents at night, except to go to the bathroom, and must wake their expedition leader in case of emergency.

· Lift and carry a backpack for hiking and working.

· Eat provided meals and drink water regularly.

· Refrain from using a cell phone or other internet connected devices, except in MCC approved situations.

· Follow directions and participate willingly in work activities, camp chores, and community living activities.

· Refrain from violence, hitting, verbal assault, bullying, any inappropriate or unwelcome touching, or any similar behavior.

· Show respect for others, work/live/play/interact in large and small groups without constant one-on-one assistance.

· Continue taking prescribed medication.

· Participate in normal activities related to self-care, health, and hygiene.

· Abide by MCC policies as explained by staff and leaders.

· Promptly notify MCC staff and/or leaders of any health condition that requires medical attention or change of activity.

· Able to sleep through the night without wetting the bed

Health History

The information on this form is to be completed by a legal guardian and is required for your child’s enrollment in any MCC program. A 'yes' to any condition does not necessarily disqualify your child.

Please check “Yes” or “No” on if your child has been diagnosed or treated for the following. Explain all “Yes” answers on the space provided below.

	Yes	No
Allergies to food, medication, or insects that trigger hives OR anaphylactic shock OR symptoms of asthma

If so, please provide a description of these allergies, and any medication they may need.

	Yes	No
Asthma/Wheezing
Seizure disorder or History of Seizures
Heart Condition or High Blood Pressure
Diabetes
Mental Health Conditions (ie. Mood Disorders, Depression, ADD/ADHD, Anxiety, etc.)
History of self-harm
History of suicide ideation, thoughts or behavior
Eating Disorders
Musculoskeletal injuries or chronic illness (ie. Back or joint injuries, history of migraines, kidney stones/disease, autoimmune disorder, etc.)
Recent Injury or Surgery
Recent Contagious Disease
Loss of consciousness due to activity
Sleep/Sleepwalking Issues
Bed-wetting

Please explain all 'YES" answers, include known triggers/hypersensitivities, indicators, frequency, actions taken to increase comfort, etc. Do not use this section for Mental Health Conditions

	Yes	No
Is your child currently seeing a psychologist, psychiatrist, therapist or other counseling specialist?

For how long?

Please share important information relevant to the reason for mental health treatment and/or diagnosis. Please include how daily life may be affected (ex: sleeping, eating, communicating, etc) and strategies for support. Include here any noticeable signs or indicators that the youth is experiencing distress, as well as triggers or factors that are known to negatively affect the youth’s level of stress.

Please describe any past/present (present, within the past 12 months) mental health concerns your child has experienced and how that’s been managed. Even if you don’t believe this will surface in the field, please share it here so we can be appropriately prepared in case it arises on the trip. The more information you're able to share, the better we'll be able to support in the field.

Pease share any past/present medical conditions your child has experienced and how that's been managed.

Please check “Yes” or “No” on if your child is current on the following vaccinations

	Yes	No
Hepatitis B
Diphtheria/Tetanus/Pertussis (DTap)
Booster Dose DTaP
Measles/Mumphs/Rubella (MMR)
Meningoccal Conjugate Vaccine (MCV4)
Polio (IPV or OPV)
Varicella (Chicken Pox)
Has your child had the disease (chicken pox)
Pnuemococcal Conjugate vaccine (PCV13)
Hepatitis A

Edit this text

Medication Information

Medications must be brought in the original bottle or container with prescription information on the bottle. The parent/legal guardian shall provide written instructions, as prescribed by the physician, and shall give written consent for the Crew Leader or MCC Staff to directly monitor the self-dispensation and self-administration of medications to MCC participants under 18 years of age.

	Yes	No
Is your child currently taking any medications (prescription or over-the-counter)?

Please list ALL medications (prescription and over-the-counter) that you plan to send with your youth to MCC, including the condition treated by the medication, the name of the medication, and - if within three months of start date - when the medication began or dosage changed. Please include information about potential side effects or adverse reactions to medications, as well as any potential signs of inappropriate/missed administration.

MCC crews carry a small amount of over-the-counter medications such as Benadryl, Ibuprofen, Aspirin, cold medicine, allergy medicine, sunscreen, bug spray or antidiarrheal in their first Aid Kits. These are not intended for regular use, but available in case a need arises.

	Yes	No
I give MCC permission to make available these type of over-the-counter medications in the event that my child is in need and has not brought their own, according to the restrictions/ directions on the bottle.

Diet and Nutrition

We provide healthy, high quality food and regularly accommodate omnivores, vegetarians, vegans and gluten- free diets. However, in the case of multiple allergies, we may not be able to provide for all special food needs. We do our best to accommodate a wide range of eating habits, but cannot guarantee that all needs can be accommodated.

	Yes	No
My child has special food needs/dietary restrictions or preferences

Please explain

Health Insurance Information

Enter “NA” for all blanks if uninsured, or “IHS” if Indian Health Service is main provider

Insurance Holder

Relationship to Participant

Insurance Company Name

Insurance Policy Number

Group #

ID #

Thanks so much for your application! Click "Finish" below to complete your submission.

After we receive your application, waivers will be sent to both parent/guardian emails. Once these waivers are signed, your application will be considered complete.