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NCCR- LDC Delegate Application 2019

Welcome

Welcome to the Leadership Development Center (LDC) hosted by the Northern California Coastal Region!

The Leadership Development Center (LDC) is a four-day overnight conference designed by youth for youth that provides learning experiences focused on leadership development, community involvement, and disaster preparedness. Delegates will become trained community disaster educators and learn how to start and effectively run a Red Cross Club. Additionally, delegates will gain invaluable experience in activities such as team-building, public speaking, diversity training, CPR/First Aid, disaster and emergency preparedness, and international humanitarian law. No previous Red Cross experience is required to apply.

Leadership Development Center 2019

Date: August 5-8, 2019

Location: Butano Creek - Girl Scout Camp

Qualifications:

5 hour service commitment to the American Red Cross following LDC-this will be required if interested in coming back to camp as a staff member in following years

Must be entering 9^th to 12^th grade

Registered Red Cross volunteer at the time of attendance

Development Opportunities:

Gain knowledge of community preparedness

Certification for CPR/First Aid

Leadership skills

LDC Fees:

The total cost for LDC is $250

$50 non-refundable deposit at the time of acceptance reserves your place.

$200 goes towards meals, lodging, t-shirt, and conference materials.

Fees can be mailed or delivered to:

American Red Cross Youth Services

3901 Broadway

Oakland, CA 94611

Attn: Allie Parker

Application Deadline:

Application deadline is June 15, 2019, and all applicants will be notified of the final decision by the middle of July.

For more information, contact the Youth Development Specialist - Allie Parker at alexandra.parker@redcross.org or Gurpreet Lally, Youth Services Coordinator- Silicon Valley, at gurpreet.lally@redcross.org

Delegate Information

First Name

Last Name

Preferred Name

Address

City

State

Zip Code

County

Gender

Date of Birth (MM/DD/YYYY)

Age

Phone Number

Grade

School Name

Which of the following do you consider yourself?

T-shirt size

Getting to Know the Delegates

1. Please list any school activities, along with any extracurricular activities you are involved with this year (activity name, description, time commitment)

2. Please list any Red Cross trainings you have received and the Red Cross service projects or activities you have participated in (none are required)

3. What motivated you to apply as a delegate for LDC 2019?

4. What do you hope to gain from your experience at LDC 2019?

5. How did you hear about LDC 2019?

Delegate Health Information

Medications: Please list all medications the participant is to receive at the conference, prescription and non-prescription, and the dosage

Would you like the LDC staff to dispense these medications while at camp?

By checking No, I, as a parent or legal guardian of the applicant, understand that the participant will be self-dispensing the aforementioned medications. I assume all risks associated with this decision and hereby waive, release, absolve, and agree to hold harmless the American Red Cross and Alliance Redwoods, its employees, volunteers, and officers for any claims arising out of injury or death to the minor.

Allergies

List all known allergies

Food Allergies

Does your child take any medication(s) for the allergy/condition?

Restrictions

Food Restrictions

Is the delegate in good health and able to participate in all normal camp activities?

Please explain any restrictions including special needs

Immunizations

Date of last tetanus immunization (MM/YYYY)

Medical History

Liability Waver

BY INITIALING THIS WAIVER, I AFFIRM THAT I HAVE READ AND UNDERSTOOD THE STATEMENTS WITHIN IT AND I AGREE TO ALL OF ITS CONTENTS.

Name of Participant

Parent/Legal Guardian initials (if participant is under the age of 18)

Today's Date

Parent/Legal Guardian Name

Parent/Legal Guardian Email

Parent/Legal Guardian Phone Number

Parent/Legal Guardian Phone Number #2

Emergency Contact Name

Relationship to Applicant

Emergency Contact Email

Emergency Contact Phone Number

Emergency Contact Phone Number #2

Scholarship

Will you require a need-based scholarship to attend LDC 2019? (Requesting a scholarship does not impact your application)

Please state why there is a need for financial assistance including any extenuating circumstances (This section must be completed in order to receive financial assistance)

If you are requesting a scholarship, how much do you need? (We cannot guarantee the entire amount requested but we will try our best to meet everyone's needs)

Have you applied for LDC financial assistance before?

If yes, what year?

Parent and Youth Orientation

Please choose the chapter that is most convenient for you to register for LDC orientation

Application Reminder

Type an email address that the applicant's acceptance packet should be sent to

Parent/Legal Guardian Typed Initials

Today's Date

LDC Applicant Typed Initials

Today's Date

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