Spring 2018 Youth Application and Parental Consent for the Teen Leadership Corps (TLC) at Awbury Arboretum
Email address *
TLC Youth Application
Youth Application
We welcome applications from all interested high school age students.

We welcome applications from ALL interested high school age youth. Work-ready middle school youth who are interested in volunteering are also welcome to apply.

Join our TLC team to grow food, cook, & create products. We learn by taking action in: gardening, environmental science, business, media, poultry care, aquaponics, food justice, community service, landscaping, and much more!

Community service hours available.
Students will be admitted on a rolling admission basis until the program is full.
We meet Wednesday afternoons & Saturdays.
Learn to earn badges, which unlock opportunities for $tipends, paid work, and leadership positions.

TLC is located at the Awbury Arboretum’s Agricultural Village, 901 E. Washington Lane, between Chew and Ardleigh. To get to the Farm Kitchen, follow the driveway to the left, then right towards the farm and the blue building w/ picnic tables. The 26, 18 and XH all stop at the intersection of Chew Ave. and Washington Lane.

For more information, email jbilger@awbury.org

Please return completed application to: TLC at Awbury Arboretum, 1 Awbury Rd., Philadelphia, PA 19138, or by email to jbilger@awbury.org.

Please print clearly, and fully complete this application. Thank you.

To Be Completed By the Youth Applicant
Name: *
Your answer
Complete Address: *
Your answer
Student Phone (May we text you?): *
Your answer
Student Email (Do you check email?): *
Your answer
High School & Grade: *
Your answer
Parent/Guardian Name: *
Your answer
Parent/Guardian Contact (Cell Phone & Email Address): *
Your answer
Parent/Guardian Contact (Cell Phone & Email Address): *
Your answer
Why do you want to be in the Teen Leadership Corps at Awbury? *
Your answer
What are your favorite academic subjects and at least one reason why? *
Your answer
Tell us about any group or teams you’ve participated in, favorite out-of-school activities, community or school projects or activities, and/or any jobs you’ve held. *
Your answer
Is there anything else you’d like us to know about yourself? *
Your answer
To be Completed by a Parent and/or Legal Guardian
TLC Form for Parental Consent to Participate
Dear Parent or Guardian:

We are excited that your child is committed to joining us for the Teen Leadership Corps (TLC) at Awbury Arboretum program and/or Philadelphia Youth Network (PYN).

In order for your child to participate in the TLC program at Awbury Arboretum and/or Philadelphia Youth Network (PYN), we need both your permission and your acknowledgement of our shared understanding of legal responsibilities. We have created a program that will give your child a chance to learn and practice skills, have autonomy and shared responsibilities for growing and preparing food, constructing websites and garden boxes and other aspects of running a small urban farm based business. Our work a will include cooperating and communicating with a variety of people in a variety of settings.

Through the school year and summer sessions, we will be working with paper and pens, computers, shovels and rakes, pruners, knives and other tools. There is some degree of risk associated with our planned work. We will provide training and supervision and do our best to offer your child a productive and safe experience, but we know that unexpected things can happen and need to be prepared. For this reason we need to know how to contact you, and also to get your permission in advance in case we cannot reach you, or if it is a true emergency and there is not time to contact you. We also need you to officially acknowledge and share these risks, as we cannot go forward with the program unless we are indemnified from risk by the parent or guardian of each participating youth (under age 18).

Please carefully read and sign this parental consent form. If you have any questions or would like further information, please feel free to contact us at TLC@Awbury.org.

Name of child: *
Your answer
Birth Date: *
Your answer
Full Address: *
Your answer
School: *
Your answer
Grade: *
Your answer
Student's Telephone # (Cell): *
Your answer
Physician's Name: *
Your answer
Physician's Telephone #: *
Your answer
Physician's Address: *
Your answer
NOTE: I understand that is my responsibility to discuss appropriate preventative treatment(s) for pre–existing medical condition(s), such as asthma or diabetes, with my child and to inform TLC staff of such condition(s) and treatment(s) in order to ensure that my child has a healthy and safe working experience. Please list below any medical conditions that we should be aware of, and please do contact us to discuss these in more detail so we can best support your child. *
Your answer
PERSONS TO BE NOTIFIED IN CASE OF AN EMERGENCY
In an emergency, we will contact parents/guardians first. Please list two additional people, in order of you want them to be contacted, in an emergency.
Name: *
Your answer
Relationship to Child: *
Your answer
Cell Phone #: *
Your answer
Additional Phone #: *
Your answer
Name: *
Your answer
Relationship to Child: *
Your answer
Additional Phone #: *
Your answer
Cell Phone #: *
Your answer
Parental Consent & Release
A paper release will be sent home and must also be signed.
Parental Consent & Release || I, on behalf of my child and myself agree to the following: • I understand that my child will be a participant in the TLC program and related activities, and I hereby give permission for him/her to serve in that capacity at TLC. • I understand that my child will be provided with the orientation and training necessary, and as needed, for the safe and responsible performance of the duties assigned. He/she will be expected to meet all the requirements of the position, including regular attendance and adherence to group agreements.• Should my child require emergency medical treatment, first aid, or transportation to a hospital or medical facility as a result of illness or injury associated with my child's participation in program or related activities, I understand that every attempt will be made to reach me, and I consent to any such treatment, first aid and/or transportation that may be provided to my child, and understand that TLC will not be responsible for any costs associated with any of the that transportation or care. • I understand that as a participant in this TLC program and related activities, my child will participate in outdoors physical activity. I represent and warrant that my child is in good physical condition, and has no physical, health related or other problems which would preclude or restrict his/her participation in this program or related activities or otherwise render his/her participation dangerous or harmful to him/her or others, and that he/she is allowed to participate in physical activity.• I understand that as a participant in the TLC program and related activities, my child will be involved in food preparation and group meals, and it is the responsibility of my child to ask about ingredients in all food he/she chooses to ingest, and I have discussed this responsibility with him/her. • I authorize the TLC program, Awbury Arboretum, and Historic Germantown to use pictures, videos, and audio of my child in any or all promotional or educational materials and social media platforms that will be produced to promote or publicize our program. If this particular issue of photo use is an issue for you, please let us know in writing. Your child is still welcome to participate in the program, and we will see that their image is not included in any promotional material.• I, the undersigned, certify that I am the parent or legal guardian of the child named above, and that I have the right to make decisions for my child that effect his/her well-being. I recognize and acknowledge that physical injury, accident, illness, death, loss of personal property, or other contingencies may befall my child as a participant in the TLC program and related activities.• I understand that my child is not in any way required to participate in the program and related activities, and despite these risks, I want him/her to participate in the TLC program. In light of the preceding and with sufficient knowledge of my child's physical and other conditions and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage, illness and/or injury to person or property which my child may, in any way, sustain in connection with his/her participation in the program and related activities. • In consideration of my child's participation in the program and related activities, I agree to release TLC and Awbury Arboretum trustees, officers, employees, agents and volunteers from any and all liabilities, damages, losses and/or causes of action (collectively, "Claims") that I or my child may suffer or have, including without limitation, to our persons or property or both, which arise out of, are related to or in connection with, or occur during, my child's participation in or attendance at the program and related activities except to the extent any such Claims are caused by the gross negligence or willful misconduct of the employees of Awbury Arboretum.• I further agree to indemnify and hold harmless The Awbury Arboretum and its trustees, officers, employees, and volunteers from any and all Claims arising out of, related to, or in connection with the program or related activities that are caused by my or my child's negligence. BY TYPING MY NAME IN THE ANSWER BOX, I AM CERTIFYING THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ, FULLY UNDERSTAND AND AGREE TO THE TERMS OF THIS AGREEMENT.
Your answer
Parent/Guardian's Full Name: *
Your answer
Parent/Guardian's Telephone No: *
Your answer
Today's Date: *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service