The Community Service Office
L.P. Young Student Center
Domestic Weekend Alternative Break Program
Participant Application
Due: Rolling Submission- First Come First Served
L.P.Young Student Center, Community Service Office
Email: jcloutier1@keene.edu Phone: (603)358-2665
Domestic Alternative Breaks (AB) are service-based immersions into different cultural,
environmental, and socioeconomic communities around the country. Participants travel in
teams, take part in service projects that address unmet community needs, gain awareness of
critical social issues, enhance their individual growth, and prepare for lives of active citizenship.
In winter and spring 2014, 3 teams will travel the weekend to Hartford, CT to take part in service
projects. Teams will work with Habitat for Humanity to provide affordable housing to families in
and around Hartford.
Applications are first come first served and will be rolling submission until all the trips are filled.
Please submit your applications to the Community Service Office. You may submit your
application in person, or by email (jcloutier1@keene.edu).
Submitted applications will be reviewed by Alternative Break Team Leaders. You will be
notified of your acceptance through e-mail once it has been reviewed. Please Note: Only
students who are in good academic and judicial standing with the College during the Fall 2014
and Spring 2015 semesters will be accepted and allowed to participate.
Trip participants will be required to pay $75 per person, through one non-refundable
payment. This price includes transportation, lodging, meals, and other supplies during the trip.
Payments are due one week after participants receive confirmation of their place on a trip.
Throughout the fall and spring semesters, AB leaders and participants will convene regularly to
prepare for the trips. Preparation will include training sessions and group meetings. All meetings
and events are mandatory; failure to attend meetings may result in dismissal from the trip. Please
consider the time and financial commitments associated with AB before you apply. Should you
have any questions during the application process, please contact Jessica Gagne Cloutier at 603358-2665 or jcloutier1@keene.edu.
Thank you for applying!
KSC Alternative Weekend Break Trips
Important Dates
.
September 10: AB Weekend participant applications released.
October-February: Applications are rolling submission until spots are filled
October 24-26 : First weekend trip travels to Hartford, CT
February 20-22: Second weekend trip travels to Hartford, CT
March 6-8: Third and last weekend trip travels to Hartford, CT
*Upon acceptance, participants are required to submit their payment of $75. Applications have a
rolling submission and are accepted on a first come first served basis. Please bring applications
to the Community Service Office, located on the third floor of the Student Center. Only cash or
check will be accepted. Please make checks payable to Keene State College. THERE ARE
NO REFUNDS.
Personal Information
First Name: ____________________ Last Name: _______________________________
Student ID #:_____________________________________________________________
Campus Address: ____________________________________Mail Stop: ____________
Permanent Address: _______________________________________________________
City: ___________________ State: __________ Zip: ____________________________
Telephone #: Home: ____________________ Cell: ______________________________
Email: __________________________________________________________________
Major(s): _______________________________________________________________
Expected Graduation month/yr: _____________ Date of Birth mm/dd/yy: ____________
Previous Service Trip(s): ______________________________________________________
T-shirt Size: ________________________________________________________________
I have read the Participant Application Cover Page and I am
prepared to meet all time and financial commitments associated
with participation in an Alternative Break Trip.
Signature
Date
Turn in applications to Jessica Gagne Cloutier, Coordinator of Community Service
Essay Questions
All applicants must answer questions 1-4 to be considered for an AB trip. Your responses are a
reflection of your interest—they demonstrate your professionalism, capacity to communicate
effectively, and ability to connect service activities to larger social issues. Please answer these
questions thoughtfully, review your answers for spelling/grammatical errors, and be honest as you
describe relevant experience(s). You may submit additional pages as necessary; please limit your
responses to 2 typed pages.
1. If selected, what do you wish to gain by participating in this trip?
2. What types of community service have you been involved in?
3. What knowledge or experience do you have that relates to affordable housing?
4. Please rank the weekend trips below in order of preference and availability of the weekend
you wish to attend. 1= first choice, 3= last choice.
OCTOBER
_____October 24th-26th
FEBRUARY
_____ February 20th-22nd
MARCH
_____ March 6h – 8th
Alternative Break Program
Keene State College
Alcohol and Drug Free Pledge and Commitment
I. Introduction
The Alternative Break Program values drug and alcohol free trips and activities. It is important
for participants to recognize that behavior in violation of this pledge can hurt Keene State
College’s relations with the community we are serving, the host countries and institutions, the
image of the Alternative Break movement, and participants’ own health and safety.
By signing the following, participants pledge to abide by the Alternative Break alcohol and drug
policy and Keene State College’s Student Code of Conduct for the duration of the trip.
Additionally, participants pledge to abide by the laws and standards of each destination they will
travel to during the program. Please note that the standards of this alcohol/drug policy are stricter
than many local laws. Students who choose to violate this pledge will be subject to the
consequences outlined below.
II. Elements of the Agreement
A. Standards
During the trip, pre-trip, or post-trip activities, participants, regardless of age, may not:
1.
2.
3.
4.
5.
Buy alcohol or illegal drugs
Consume or be under the influence of alcohol or drugs
Hold alcoholic beverages or drugs for oneself or another person
Be identified with people drinking alcohol or using drugs.
Appear in representation where alcohol or drug consumption is implied,
encouraged, or condoned (this includes but is not limited to social media networks
such as Facebook, Twitter, Instagram, etc.).
6. Wear clothing or other accessories with relatedness to drugs or alcohol
B. Violation
If a participant is suspected of a violation for drugs or alcohol, the following steps will be
taken:
1. A trip leader will address the incident.
2. A discussion about the incident will be held between the participant, a trip leader
and a faculty/staff advisor as soon as a trip leader is informed of an incident. Trip
leaders and faculty/staff advisors hold an authoritative role in any such situation.
3. If a participant is found using or in possession of alcohol and/or illegal drugs,
local law enforcement will be contacted.
4. If it is determined that the policy has been violated, the participant may be sent
home at his/her own expense.
5. For all violations, students may be referred to the campus conduct system
following return from the trip.
6. For all violations, future participation in the program will be left to the discretion
of the Coordinator of Community Service.
C. Student Conduct Code
1. Participants will comply with Keene State College’s rules, standards and
instructions for student behavior, including but not limited to the College’s
Student Conduct Code, both on and off campus. Violations are subject to referral
to Keene State College’s Student Conduct Office.
By signing below, I confirm that I have carefully read and clearly understand the
statement above. I have reflected on my reasons for participating in Keene State
College’s Alternative Break Program, and I agree to abide by this pledge. I understand
that if I violate this agreement I may be sent home at my own cost and my future
participation in this program may be temporarily or indefinitely suspended.
Additionally, I understand that I may also face consequences through Keene State
College’s conduct process. If I observe anyone violating this program’s Alcohol and
Drug Pledge, it is my responsibility to report the violation to a trip leader/staff advisor
immediately.
I hereby release and agree to indemnify, defend, and hold harmless Keene State College
from the consequences of any breach of my pledge and commitment.
I have had the opportunity to ask questions and receive explanation for any statements
and policies that I do not understand.
I have read and fully understand the above provisions and agree to be bound by them, as
indicated in my signature below.
Printed Name: ___________________________
K.S.C ID:___________________________
Signature: ___________________________
Date: ___________________________