Alternative Spring Break Leader Application
Complete this application, essay and agreement and submit it Elizabeth O’Leary, Service Trip
Coordinator, in DUC 050.
Applications due: May 1, 2015
Name:
Address:
E-mail:
This is the way we will communicate with you! Please check regularly.
Phone:
T-shirt Size:
Anticipated
Graduation:
(Semester and Year)
Are you willing to drive a provided university mini-van, and do you have a valid driver’s license? If yes,
fill out the driver’s authorization form included in the application.
Essay Questions: Please answer the following questions by typing responses on a separate piece of
paper. Incomplete applications will not be accepted.
1) Why are you interested in becoming an Alternative Spring Break Leader?
2) How have your experiences prepared you to lead a service trip? (Please include any prior
volunteer experience you have with our office and other organizations)
3) Our mission is to create active citizens through the service trip experience. An active citizen is a
person whose community becomes a priority in life choices and values. How would your
leadership on this trip further our mission?
4) In your opinion, what are aspects of a successful service trip?
5) What fears or questions do you have about leading a project?
SIEO Alternative Spring Break Leader Agreement
Before submitting this agreement, please read all statements below carefully, consider them seriously,
and sign to indicate your agreement. Thank you.
COMMITMENT/EXPECTATIONS:
Our programs are successful because of dedicated, active volunteers. Please consider all volunteer
expectations before you apply. Failure to meet expectations may result in dismissal from position.
1. Full attendance and participation in all mandatory functions, possibly including:
a. Trainings
b. Orientation Meetings
c. Staff Meetings
d. Regular meetings with your coordinator
e. Other as they arise
2. Active participation in fundraising for your trip, if applicable
3. Remain flexible, open-minded, respectful and responsible
4. Completion of tasks before, during, and after the service trip/event including meeting with your
coordinator, selection of trip location, service planning and post trip follow up
5. Creating and insuring an inclusive environment for all participants, community partners, sites
and clients
6. CPR Certification (SIEO will provide training, if you are not already certified)
By signing this statement, I am agreeing to invest the time, energy and commitment to fulfill the
expectations as outlined above.
Signature:______________________________________________ Date:__________
SITE LEADER PARTICIPATION AND CONDUCT:
Site leaders and participants are required to follow all SIEO and UWSP policies and state and federal
laws before, during, and after their volunteer experience. As a site leader, I am responsible for
cooperating with, and respecting the authority of the project coordinator as well as overseeing the
conduct of the volunteers. I understand that any breach of student conduct rules and regulations of
UWSP and/or the service site will be reported to the appropriate student conduct authority on campus.
By signing this statement, I am agreeing to follow and uphold SIEO and UWSP policies
Signature:______________________________________________ Date:__________
ALCOHOL/DRUG FREE POLICY:
This UWSP service trip is an alcohol and drug free program. This is done in order to achieve the
program’s goals and objectives. This is also required for the safety and well-being of all participants, the
group, and the community in which we are serving. As such, I will not possess and/or consume alcoholic
beverages and/or illegal drugs while participating in the service trip. Should this policy be violated, I will
be asked to leave the trip and will be responsible for making my own arrangements and paying for the
trip home.
Signature: ___________________________________________ Date:__________
If you do not understand any of the statements or need clarification, please contact SIEO BEFORE
submitting the agreement.
I have read all above statements and considered them seriously. I fully understand all above
statements and agree to comply with them.
Signature:______________________________________________ Date:__________
___________________________________________________________________
Medical Information
NAME OF STUDENT PARTICIPANT _______________________________________
In Case Of Emergency, Contact______________________________________________
At The Following Number__________________________________________________
Health Insurance Company Name___________________________________________
Policy Number__________________________________________________________
_____________________________________________________________
University of Wisconsin – Stevens Point
PHOTO & VIDEO RELEASE
I hereby authorize Student Involvement and Employment Office and the University of
Wisconsin Stevens Point and those acting pursuant to its authority to photograph, video tape,
or use any other electronic method of recording my likeness and/or voice to be used at the
University’s discretion in University-related publications and/or web sites. The photographs
and/or video footage will not be digitally manipulated to change its content.
I hereby give the University the absolute right and permission, without restrictions, to make,
copyright, and/or use, re-use, or publish said photographs/video footage of me in which I may
be included in whole or in part, and waive any right to inspect and/or approve the finished
printed materials, videos and/or web sites where my image appears. I further consent that my
name and identity may be revealed therein or by descriptive text or commentary.
I release the University and those acting pursuant to its authority from liability for any violation
of any personal or proprietary right I may have in connection with such use. I understand that
all such recordings, in whatever medium, shall remain the property of the University.
I waive any right to compensation for my appearance in these printed documents, videos or
web sites in any and all future uses of the photographs and/or video footage.
I have read and fully understand the terms of this release.
(If you are under 18 years of age, a parent or guardian must sign.)
Signature _________________________________________________
Printed Name ______________________________________________
Minor’s Name (if applicable) __________________________________
Address ___________________________________________________
City/State/Zip ______________________________________________
Date ______________________________________________________