31 st Annual High School Leadership Conference November 5-6, 2016 Shanty Creek Resort, Bellaire, Michigan Group Conference Registration Form - A
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1 31 st Annual High School Leadership Conference November 5-6, 2016 Shanty Creek Resort, Bellaire, Michigan Group Conference Registration Form - A Name of School/Group: School Phone: ( ) School Fax: ( ) School Address: City: State: Zip: Advisor (s) Name: Advisor (s) Cell Phone: Advisor Home Phone: ( ) Advisor _ Student Contact: Student Cell Phone: ( ) Student We will bring a chapter banner/display We will bring a chapter/group table display Advisor(s) Name(s) Home Phone Student Name(s) Gender How many conferences have you been to # of Students + # of Advisors = Total # of Participants For every participant you must complete 1. Emergency Medical Form C 2. Participant Registration Form D *Please attach additional participant lists if needed Cost Worksheet Important: Conference 2016 begins Saturday November 5 and ends Sunday November 6 (3:00pm). See agenda for details. Early Registration fee (full payment received by 9/30/16) $50 x # of participants = $ Regular Registration (full payment received after 10/1/2016) $65 x # of participants = $ Late Registration (full payment received after 10/16/2016) $75 x # of participants = $ *Participating Chapter Membership Fee : $50 per chapter/group = $_50.00 Note: Participating Chapter Membership Fee is waived for 2016 SLS Chapter Study Participants. *If registrations are not made by October 19, There is no guarantee there will be hotel rooms available. First come, first serve. TOTAL: = $ Payment Methods: Check (made payable to Student Leadership Services, Inc.) Purchase Order # Registration Checklist Before sending your registration packet please be sure ALL of the following are included: Group registration Form A and any attachments Hotel Group Registration Form B with method of payment indicated payable to SHANTY CREEK RESORT Copy of school state tax exempt letter Participant Medical Form C for all participants including adults Participant Registration Form D for all participants including adults Please send all REGISTRATION and HOTEL information to Student Leadership Service, Inc. at the address below. Registration Deadline is October 19, Because of space limitations, registration is based on a first come, first serve basis. Registrations received after October 16 will be accepted with a $10 per person late fee. CANCELLATION POLICY: Student Leadership Services, Inc. requiresa 10 day prior notice to cancel individual or group registration for atraining, conference or event. No refunds or credits will be grantedwithout 10 day notice.
2 PLEASE RETURN THIS FORM WITH ALL THE CONFERENCE REGISTRATION MATERIALS TO SLS: 1150 Scott Lake Rd Waterford, MI Group Name: Address: Contact Name: Home Phone: City: State: Zip: Business Phone: Confirmation Fax: You are welcome to arrive early or extend your stay following this scheduled event. At times specified accommodations are not available prior to or following your event. If the room type requested is not available, we reserve the right to assign the next available room type and rate. Arrival Date: Departure Date: # Adults: # Children: The rates below are PER PERSON ROOM TYPE: Single Double (Per Person) Triple (Per Person) Quad (Per Person) Guest Room (2 double beds) $133 $90 pp $76 pp $68 pp Studio Parlor (1 king bed) $160 $104 pp Roll Away Beds $20 (Each) The above per person (pp) rates include: 1 night lodging (Saturday), 1 dinner (Saturday), 1 Breakfast (Sunday), 1 Lunch (Sunday) taxes, resort fees and gratuities. Note: Conference 2016 begins Saturday November 5 and ends Sunday at 3:00pm November 6 Early arrival rate for 11/4 is $90.41 per room (Friday meals and Saturday breakfast and lunch are on your own). Room 1 (Indicate if adult) Gender Room 2 (Indicate if adult) Gender Indicate if you need roll-away Room 1 Hotel Cost Indicate if you need roll-away Room 2 Hotel Cost Room 3 (Indicate if adult) Gender Room 4 (Indicate if adult) Gender Indicate if you need roll-away Room 3 Hotel Cost Total Hotel Cost for November 5-6, 2016_ STUDENT LEADERSHIP SERVICES November 5-6, 2016 Form B Registration Deadline October 19, 2016 Indicate if you need roll-away Room 4 Hotel Cost Early Arrival (Friday) Hotel Cost (90.41 per room) Total owed to Shanty Creek THIS FORM MUST BE MAILED OR FAXED IN TO RECEIVE THE GROUP DISCOUNTED RATES. Card Number: Expiration Date: (If Mailing a Check, Please Note on the Line Above.) (Please make hotel reservation check out to Shanty Creek Resort) Signature (Required): Do you have any special lodging requests? Barrier Free: For Questions or More Information, Please Call: SLS at
3 31 st Annual High School Leadership Conference November 5-6, 2016 Shanty Creek Resort, Bellaire, Michigan Student and Adult Emergency Medical Form - C Name: Birthdate: Age: Gender: School/Group Circle one: Adult Student Parent/Guardian (if under 18 years): Phone: ( ) Address: City: Zip: Alternate Contact: Relationship: Phone ( ) Health History: (please check and date all that apply) Ear Infections Chicken Pox Hay Fever Rheumatic Fever Convulsions Diabetes German Measles Mumps Measles Behavior *Please explain below Asthma Other Allergies: (please check all that apply) Insect bites Penicillin Other drugs Date of last tetanus shot Sensory impairments Chronic problems or illness Serious injuries (dates) Recently or currently being treated for some medical problem Physical limitation to normal activity List medication currently being taken Insurance Information: Policyholder's name and Relationship to Patient Policyholder's Address Name and address of Insurance Company Name and Address of Employer ALL Policy Numbers (please identify) I,, being the natural parent/legal guardian of, a minor who resides at, hereby grant Student Leadership Services, Inc. (SLS), or its designee, the right to transport the above-captioned minor, to any emergency medical or health care facility for immediate treatment and/or consultation, if necessary. Further, I hereby grant SLS's medical director or his/her designee, the right to consent on behalf of the above-captioned minor for medical treatment. I understand that I will be notified of any emergency situation immediately, but that this emergency medical release is in the event that I am unavailable to the necessary parties, and immediate authorization for treatment is required. SLS's medical director or his/her designee is hereby authorized to incur medical cost necessary to provide medical treatment of said minor, for which we shall be fully responsible. I also authorize the medical facility to release any and all information required to complete insurance claims and also authorize insurance payment directly to the medical facility. Signature: Natural Parent/Legal Guardian for, a minor. Date:
4 31 st Annual High School Leadership Conference November 5-6, 2016 Shanty Creek Resort, Bellaire, Michigan Participant Form (Student and Adult) - D All forms from each school should be returned together. Each participant (students and adults) must fill out both a registration form and a medical form. For more information call Student Leadership Services at (248) Please type or print legibly: Circle One: Student Advisor Parent Other Name: Dietary Requests/Concerns: Address: City: Zip: Phone: ( ) School: Gender Age: Grade: How many SLS Conferences have you been to? Besides Conference what other SLS trainings have you participated in? T-Shirt size Small Medium Large X-Large XX-Large XXX-Large *T-shirts are first come, first serve and are not guaranteed. Emergency Contact: (Adults too!) Name: Home phone: ( ) Alternate: Home phone: ( ) Relationship: Work / Cell (circle one): ( ) Relationship: Work / Cell (circle one): ( ) Photographs and videos will be taken during the conference to be used for SLS Social Media. May we use your photo/video? Y N Required for all high school student participants: As parent/guardian, I have read and reviewed the rules of the SLS High School Leadership Conference and I have discussed them with my son/daughter. My son/daughter understands all the rules and agrees to follow them. I agree to hold SLS, its agent's staff or successors-in interest, harmless from liability due to my son/daughter's violation of any of these rules. I understand further that conference fees or lodging costs will NOT be refunded as a result of early dismissal. Signature: natural parent/legal guardian for, a minor. Date: COSTS: EARLY Registration: $50 - Includes all conference materials and is payable to Student Leadership Services, Inc. Student Leadership Service will accept individual or personal checks or school checks. Regular Registration (after 9/30) is $65; Late Registration (after 10/16) is $75 Participating Chapter Fee: $50 per participating chapter/group/school for the entire school year. When you become a Participating Chapter you receive countless benefits such as discounted/free training rates, scholarships, assemblies, grants and the latest prevention research. *Participating Chapter Fee waived for 2016 Chapter Study Schools. Shanty Creek Resort: The fees listed below include rooms, meals, taxes and gratuities. Arrange payment to your school/group with your adult advisor. Schools must submit group check or credit card for lodging to Shanty Creek Resort. The hotel rate also applies to spouses accompanying advisors. Same sex students from same school will be housed together. $68.00 (Quad) per person people per room $76.00 (Triple) per person - 3 people per room $90.00 (double) per person - 2 people per room $ (Single) - Available to advisors only $20.00 Rollaway Each CONFERENCE REGISTRATION DEADLINE: OCTOBER 19, Late fee after October 16 - $10 per participant This form should be returned along with your medical form, to your adult advisor
5 Student Leadership Services Workshop Proposal Form November 5-6, 2016 ** Workshop Proposal Deadline: October 15 ** One of the highest rated parts of the past 30 conferences has been the student-led workshop sessions. We invite workshop proposals from students, advisors and anyone interested in presenting. This year s theme is UNSTOPPABLE please find a way to incorporate the theme into your workshop. Please fill out the following information and return it to the SLS office. Please type or print Name: School/Organization: Street Address: City: State: MI Zip: Phone: ( ) ext. Fax: ( ) Advisor Name (if school): Advisor Phone: ( ) Student Contact (if school): Student Home Phone: ( ) Workshop Proposal: Proposed Program Title: Total number of PRESENTERS (including Advisor): If selected you will be guaranteed a minimum of 1 session, however if space is available, what is the maximum number of presentation you wish to present? Please give a program description (abstract - 25 word maximum) to be printed in the Conference program: Please give a brief description outlining the major points to be covered during your workshop. NOTE: Good workshops are interactive! Please BE PREPARED and include an energizer at the beginning and an appropriate fun closing as well as participatory activities to deliver your message. Workshop Style/Format Low High (Circle one) Discussion Group Participation Role Playing Noise Level All workshop rooms are set up either theater style or Classroom Style with a flipchart and markers. If you have a preference please note it on proposal. Please bring your own audio/visual including extension cords as SLS will not provide. You can expect between participants per workshop. Please contact SLS if you need special assistance. Decoration may be secured with tape. Please return this form to: Student Leadership Service, Inc., 1150 Scott Lake Rd., Waterford, MI dmf@slstoday.org (To ensure delivery if sending in via - please be sure to put "SLS Conference Workshop Proposal" in the subject line) Student Leadership Services, Inc. * 1150 Scott Lake Rd. * Waterford, MI Phone: (248) * Fax: (248) * Website: ;
6 Student Leadership Services, Inc. Award Package Deadline for Nomination Awards: October 15, 2016 Criteria: Please review the following criteria for award nominations. Fill out the attached Nomination Form. Make sure to complete the form to your best knowledge and identify which award you are selecting for nomination. The Student of the Year nomination has a separate Nomination Form with the criteria in detail. Award recipients will receive an invitation to attend SLS s state event and a plaque. SLS Advisor of the Year Enables the chapter and students to develop to their maximum potential. Uses their strengths in a positive way to enhance the chapter. Exemplifies the chapter s beliefs in everyday life. Shows dedication in being an advisor. Involved and dedicated in helping with the chapter s goals. Commitment and dedication to their chapter for at least two years. SLS Chapter of the Year A group of students and an advisor(s) who support and exemplify spreading the ideals of Student Leadership Services and youth led prevention. Students and Advisor work and function as a team. The Chapter of the Year must have shown development each year making their chapter stronger than the previous year. The Chapter of the Year must have reached out to a significant amount of youth in the school. This chapter must have made a considerable impact in their school and demonstrate how the impact is evident. SLS Charlie Stilec Spirit Award Chapter exemplifies positive energy, enthusiasm and dedication to the vision of Student Leadership Services. Chapter participated in at least two community service projects in a school year. Chapter planned and participated in at least two substance free activities at school. Chapter displays mission and values in all aspects of chapter meetings and activities.
7 SLS Most Improved Chapter Has shown significant improvement in majority of the following areas: o Members o Increased money from fundraisers, events, etc. o SLS activities o Sponsorships o Chapter Activities o Other improvements and accomplishments Applicants need to show before and after summaries of school climate, etc. SLS BEAR Award (Named after Russell Reiterman, Advisor of the Year 2000, Henry Ford II High School) Welcomes students with an open mind and open heart. Engages youth to believe in the mission of Student Leadership Services. Empowers students to use their strengths. Is a respectful mentor to youth. SLS Unsung Hero (Named after Doris Vega, former SLS Staff and dear friend and mentor of SAB Alumni) Supports students, chapter and Student Leadership Services behind the scenes. Gives thankfully and unselfishly with an open heart. Respected by students, advisors and Student Leadership Services staff. Goes above and beyond with no expectation of recognition. SLS Volunteer of the Year Has devoted time and effort to Student Leadership Services. Contributes to the events hosted by Student Leadership Services. Help Student Leadership Services in accomplishing the organization s goals. Cannot be currently employed by Student Leadership Services. Must be actively involved with Student Leadership Services.
8 Outstanding Grant Project Award Creative use of community, school and student resources to match grant funding. Project reaches beyond the norm of school-based prevention projects. Evidence of youth-led strategies in the grant application, project, marketing and publicity. Evidence of school administration support and community collaboration efforts. Grant Report and Evaluation submitted to SLS in a timely, complete and thorough fashion. Hand written thank you note sent to Citizens Insurance Company representative. Community Partner of the Year Award SLS Chapter partners effectively with local businesses, community foundations, schoolbased community groups, service organizations, law enforcement, health and safety services, religious services, business professional organizations, and tourism entities. SLS Chapter/students take the lead in this partnership and continue throughout the project. Evidence of effectiveness of the project in reaching project goals. Samples of public relations and media exposure for chapter and project. The below PGVP Lifetime Award is personally selected by SLS and not nominated. Pamela G. Voss-Page Lifetime Achievement Award At least 10 years of involvement with Student Leadership Services. Has performed outstanding service to Student Leadership Services. Personal sacrifice including financial support. Examples of significant involvement: o Provided services to Student Leadership Services at events. o Devotes time to a chapter. o Helps to promote Student Leadership Services ideals. o Former member of SLS or Student Advisory Board. Is currently involved with Student Leadership Services and devotes time to the organization. Cannot be currently employed by Student Leadership Services. Deadline for Award Nominations: October 15, 2016 Awards will be presented at the SLS High School Conference November 5-6,2016
9 Student Leadership Services Award Nomination Form Deadline: October 15, 2016 Please fill this form out for each award nomination. Feel free to make copies of this form. Note: Awards will be presented at the SLS High School Conference November 5-6, 2016 Chapter information: Please type or print Nomination is for the following award: School Name: Street Address: City: State: MI Zip: Phone: ( ) ext Fax: ( ) Advisor Name: Advisor Phone: ( ) Student Contact: Student Phone: ( ) How long have you or your chapter been involved with Student Leadership Services? How do you explain the ideals of SLS? How do you or your chapter fit with the mission and vision of Student Leadership Services? Please explain how you or your chapter fits with the criteria for the specific award that is being nominated? In other words, why do you deserve this award? What are your or the chapter s biggest strength in a youth-led prevention group?
10 Student Leadership Services, Inc. Student of the Year Nomination Form Deadline: October 15, 2016 Recipient will receive a plaque, $300 college scholarship and SLS recognition/representation during community opportunities. Student Information: Please submit this form with two (2) letters of support Please type or print Name/Grade/Age: Address: City/State/Zip: Phone ( ) ext. High School: Advisor: How long has the student been in a youth-led prevention club/group? How has the chapter or group benefited from having this student as a member? Please give one word that best describes the student and why? Why does the student deserve this award? What makes him/her of high caliber of a SLS High School Student of the Year? Your Name: Relationship (if not his/her advisor): Phone: ( ) ext
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