Teens in Action 2021-2

1. Teens in Action Information

100% of survey complete.

Teens in Action Service Learning and Leadership program is designed to assist students develop leadership and complete a portion of the community service requirement. All student who wish to participate in Freshman Orientation, service projects, school opening service activites, service road trips, and social events need to complete this form. All Students should complete this questionnaire so that we can be in contact with your regarding the Service Learning Program. Questions can be directed us at TeensinAction@campfirepatuxent.org

Question Title

* 1. Please provide the following Registration Information for participation in Teens in Action Middle and High School Service learning Program. It is our practice to communicate with both the students and the parents for risk management reasons. Youth receiving emails at their own address must also have listed a parents email address for this reason. Parents please ensure that your teen has completed this form

Last Name

First Name

Date of Birth

Age

Graduation Year

School

Home street address

City

State

Zip

HOme phone

Student Cell phone

Student Email Address

Do you speak Spanish Fluently

Do you speak French Fluently

Parent 1 Parent/Guardian's First Name

Parent 1 Parent/Guardian's Last Name

Parent 1 Parent/Guardian's Email address

Parent 1 Parent/Guardian's Preferred contact number

Parent 1 Occupation

Parent 2 Parent/Guardian's First Name

Parent 2 Parent/Guardian's Last Name

Parent 2 Parent/Guardian's Email address

Parent 2 Parent/Guardian's preferred Contact number

Parent 2 Occupation

Emergency Contact if Parents are not available Name

Emergency Contact Relationship

Emergency Contact Phone number

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* 2. Do you have any medical conditions or allergies that we should know about to keep you safe during Camp Fire Activities? Please provide an explanation in the box below.

	Yes	NO
Allergies to Medications	Allergies to Medications Yes	Allergies to Medications NO
allergies to Food	allergies to Food Yes	allergies to Food NO
Medical Conditions	Medical Conditions Yes	Medical Conditions NO
Are your immunizations up to date?	Are your immunizations up to date? Yes	Are your immunizations up to date? NO
Was your last tetanus shot in the last 12 months. Please list date in box below?	Was your last tetanus shot in the last 12 months. Please list date in box below? Yes	Was your last tetanus shot in the last 12 months. Please list date in box below? NO
Are you taking any medications	Are you taking any medications Yes	Are you taking any medications NO

Explain any Yes Answers in this space

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* 3. What type of activities would you like to be involved in with Teens in Action

Service Learning Road Trips

Virtual Service Opportunties with Children

Virtual Service Opportunities with Senior Citizens

School based service projects

Social Events and Activities

Earning Presidential Service Awards

Earning Congressional Service Awards

Participating in activities that build academic skills

Participating in Teen CERT-Emergency Readiness Program

Participating in Teen Financial Management Program

Participating in Teen Driving Safety Program

Participate in Camping and Outdoor activities.

Learning how to be an Activist on social issues

Participating in Camp Fire USA Leadership Activities and Conferences

Participating in Teen Conferences that are held in various locations around the country.

Serving as a Camp Fire Representative to regional or local boards

Helping with fundraising for scholarships and projects

What other things would you like to do?

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* 4. By completing this section, you agree to guidelines of Camp Fire USA and Teens in Action. Teens in Action youth are required to complete a code of conduct as part of their participation in our programs. This form is available on the forms section of www.campfireusa-patuxent.org. Youth are also required to have parental permission to participate. A fee of $35 per year is charged for membership and insurance which is payable upon receipt of the invoice.

I understand these requirements and want to be part of Camp Fire USA Teens in Action. I understand that I will receive a signature page and the code of conduct after I complete this form.

I have advised my parents of my intentions to be part of the Teens in Action Program

Yes

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