ADAPT’s Youth Leadership Team Application
Program Description
ADAPT will be selecting youth leaders between the ages of 13-18 from across Essex County. Youth leaders will form regional teams in their respective parts of the county. Youth will learn about program planning, implementation, and evaluation to make community-level change as it pertains to drug and alcohol prevention.
Meetings are one to two times a month, all year round. Transportation can be provided and will be coordinated if you are accepted into the program.
Eligibility Requirements
Applicants must be between the ages of 13-18.
Applicants are required to live in Essex County, NJ.
As of 8/21/14 meetings are located: (meetings subject to change)
East:2nd Wed of month, 6pm, 170 Scotland Rd. Orange, NJ
South: 1st and 3rd Mon of month, 7pm, 26 Monmouth Ct. Livingston, NJ
West: 2nd Tues of month, 7pm, 880 Bloomfield Ave. Verona, NJ
Applicants are required to attend ALL Mandatory meetings, especially during the school year. (Regional teams meet once or twice a month, countywide youth leadership council meets once a month, not on dates of regional team meetings)
- Active members will be participating in monthly meetings, be part of the decision making process of the activities of the ADAPT Youth Leadership Teams, and do the activities of the Youth Leadership Teams.
- If chosen to be part of the countywide youth leadership council, the active member will participate in those meetings, be responsible for training regional teams, and serving as liaison to their respective teams.
Application process
- Applications must be RECEIVED in the ADAPT office (see address above) no later than 5:00 p.m. Friday, October 3, 2014. All applications can be submitted by mail, FED EX, UPS, hand delivered, or e-mailed to the ADAPT office.
- The ADAPT Committee will select team members based upon demonstrated leadership, interview process, as well as gender, ethnic and geographic diversity
- Letters notifying applicants of the selection committee’s results will be mailed October 10th, 2014. The induction ceremony for Youth Leadership Team members will be November 8, 2014.
ADAPT REGIONS
East Region:
-Belleville
-Bloomfield
-East Orange
-Glen Ridge
-Montclair
-Newark
-Nutley
South Region:
-Irvington
-Livingston
-Maplewood
-Millburn
-Orange
-South Orange
West Region:
-Caldwell
-Cedar Grove
-Essex Fells
-Fairfield
-N. Caldwell
-Roseland
-Verona
-W. Caldwell
-W. Orange
Please read the application instructions carefully on page one before completing the application.
Please type application if possible. If not, please write neatly and legibly.
Applicant Name
LastFirstMiddle Initial Preferred Name
Mailing Address
Address (include apt or unit #) City State Zip Code
**Home Phone ( )______**Cell Phone ( )______
Date of Birth ______Age: ___ Gender:FemaleMale
**Applicant Email_
Best way to reach applicant: Home Phone Cell Phone E-mail
Parent/Guardian______
**Home Phone (_) **Cell Phone ()
**Parent/Guardian Email______
**a lot of communication is done via phone and/or e-mail. If your child is accepted, please let us know if any contact information changes**
School Name ______Grade: ______
School Contact Person/Counselor ___ School Contact Email
Name of Hometown Newspaper ______T-Shirt Size
I found out about ADAPT through: school counselor/teacher/etc. ADAPT Youth Leader ADAPT Adult Coalition Member
other, please specify
______
Name of Person Referring/Endorsing you and Relationship:
______
Top 3 Days/Times Available for meetings:
1. Day/Time:______2. Day/Time:______3. Day/Time:______
Are you available for summer meetings? YesNo
Availability for Summer meetings (Dates/Days/Time: i.e. June –Jul Mon,Tues,Thurs after 3:30) ______
Optional Information: ADAPT does not discriminate based on race, ethnicity, sex, creed, national origin or disability. This information is not required. It is requested to facilitate our goal of assembling a diverse team.
Race/Ethnicity: American Indian Asian African American
Hispanic White Other: ______
Please let us know the organizations or activities you are involved in, both in your school and/or community. These should be in order of importance, listing up to five; school, social, athletic, religious, community service, scouting or other activities and organizations in which you have participated during the last two years. If you have held a leadership position in that group- please specify what kind.
1.
2.
3.
4.
5.
How would your principal/school faculty describe you?
How would your family describe you?
How would your friends or neighbors describe you? ______
List any accomplishments, awards, honors or recognitions for academic, school, religious or community activities you have achieved or received in the last two years.
List any community service or volunteer work experience and briefly tell what was involved.
List any work experience in which you were compensated for and briefly tell what was involved.
(ONLY FILL OUT IF YOU ARE IN HIGH SCHOOL) What are your plans after high school? ______
What do you consider to be one of your strengths?
What do you consider to be one of your weaknesses?
Who is someone you admire? ______Why?
What do you do for fun?
If you could change anything in our community, what would it be and why?
Pride, leadership, service: What do these mean to you and to the future of ADAPT?
Why are you applying for ADAPT’s Youth Leadership Team? ______
______
Consent for Reproduction of Photographs and Voice
In the course of the program, newsletters, public service announcements, newspaper and magazine articles, web site features and videos may be used. Participant gives unlimited permission to ADAPT, its nominees, agents and assigns to use, publish and republish for purposes of advertising and trade for such use as it may determine, information and reproduction of Participant’s likeness (photographic and otherwise) and voice related to participation in ADAPT.
______
Signature of Participant
______
Signature of Parent or Legal Guardian of Participant
Consent for Medical Treatment
In the event that medical treatment is necessary, Participant gives to ADAPT, its nominees, agents and assigns permission to obtain treatment at a medical facility.
______
Signature of Participant
______
Signature of Parent or Legal Guardian of Participant
ADAPT
Code of Responsibility
Statement of Purpose
The purpose of ADAPT Youth Leadership Teams is to prepare Essex County youth to make a positive differencewithin their community, that will have an impact on their peers and community members. Participants are selected because of their proven leadership qualities and/or commitment to make a difference in their community. The actions of program participants reflect on ADAPT and affect the results the program is intended to achieve.
Participation in ADAPT carries the responsibility of leadership. Participants are expected to observe the highest standards of behavior and to set an example for others to follow.
This Code of Responsibility is intended to describe minimum acceptable standards and the consequences of failure to meet these standards. Those who fail to observe these standards will be held accountable for their actions.
Applicability
This Code is applicable to all participants in ADAPT, including class members, adult volunteers and staff. This Code is applicable at all times.
ADAPT seeks to encourage personal growth and development of the skills and behavior required of good leaders. By participating in ADAPT activities, all participants acknowledge that their actions are subject to this Code. By permitting a youth leader to participate, the ADAPT member’s parent(s)/guardian(s) gives their consent to the applicability of this Code.
Policy on Attendance
ADAPT is an integrated series of experiences designed to be completed as a whole by a consistent group of participants. Attendance and participation at all scheduled events is necessary to obtain the full benefits of the program.
ADAPT members must attend all mandatory meeting, especially throughout the school year. County council members ( 6 members, 2 from each team) must attend 90% of county council meetings. The dates are to be determined and will be given to participants and their parents/guardians as soon as it is announced.
Discipline
Appropriate behavior is expected of all participants within the parameters of law and local school policies. A participant may be suspended from participation if such action is determined by the ADAPT staff to be necessary to protect the safety and security of persons or property or to avoid disruption of a class event. The disciplinary action selected will depend on the nature of the offense and the facts and circumstances in which the violation occurred.
Policy of Smoking and Tobacco Use
ADAPT is smoke and tobacco free. Participants are expected to refrain from smoking or other use of tobacco during ADAPT activities and events.
The Code of Responsibility page may be kept by the applicant for reference upon selection for participation.
ADAPT Youth Leadership Team
Code of Responsibility
Agreement Form
I,, (Participant) certify that I have read and understand the Policies of ADAPT’s Youth Leadership Team Involvement in the Code of Responsibility and that I will abide by these Policies.
______
Signature of ParticipantSignature of Parent/Guardian
______
DateDate
Applications must be received in the ADAPT office no later than 5:00 p.m. October 3, 2014.
ADAPT Youth Leadership Team
Commitment Form
This form must be signed by all three parties as indicated and returned with the application by the 5:00 p.m. October 3, 2014 deadline.
Applicant Name (please print)
I understand that a student who is admitted to the ADAPT Youth Leadership Team program is given a space in the program that is then not available to other applicants. Consequently, students who apply for the program MUST intend to accept admission and participate fully in the ADAPT Youth Leadership Teams’ program.
FOR HIGH SCHOOL STUDENTS ONLY: I have reviewed the completed application packet and support this nomination. I also verify that the applicant’s grade point average is ______.
FOR MIDDLE SCHOOL STUDENTS ONLY: I have reviewed the completed application packet and support this nomination. I also verify that the applicant’s grades are mostly ______.
______
ApplicantDate
______
Applicant’s Parent/GuardianDate
______
School OfficialDate
Recommendation Letter
Please include two (2) letters of recommendation:
1. one from an adult not related to you (teacher, youth group leader, club advisor, neighbor, etc.)
2. one from a peer
This letter can be mailed with the application or sent in separately by the October 3, 2014 deadline.
This letter should tell how long and in what capacity the reference has known you, what contributions you would bring to the ADAPT Youth Leadership Team experience, how you might benefit from the experience and anything else that would give the ADAPT committee a more complete picture of you.
ADAPT Youth Leadership Team Application Check-List
Please make sure to have your application complete.
- Application______
- Signed Consent for Reproduction of Photographs & Voice ______
- Signed Medical Release Form______
- Signed Code of Responsibility Form______
- Signed Commitment Form______
- Recommendation Letter______
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APPLICATIONS DUE 10/3/14