The Community Service Office
L.P. Young Student Center
Alternative Break Program
Participant Application
Due: Friday, October 10, 2014 at 4:00 p.m.
L.P.Young Student Center, Community Service Office
Email: jcloutier1@keene.edu Phone: (603)358-2665
The Alternative Break Program (ABP) consists of domestic and international service-based
immersions into different cultural, environmental, and socioeconomic communities.
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 2014-2015, teams of Keene State College students will travel to host
communities to take part in various service projects. All applications must be submitted by
Friday, October 10, 2014 at 4:00 p.m. 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 by October 17th, 2014. If you are applying for
Alternative Break International (ABI) you will need to sign up for an interview spot in the
Student Center Administrative Offices prior to the application deadline. 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 all applicable fees in person, through two separate
non-refundable payments. ABI participant fees are $900.00 per person and Domestic AB
participant fees are $450.00 per person. This price includes transportation, lodging, meals, and
other supplies during the trip. The first payment for ABI is $450.00, the first payment for
Domestic AB is $225.00. Note: All first payments will be due on October 24th, 2014. Please
refer to the next page for additional payment schedules.
Throughout the fall and spring semesters, ABP leaders and participants will convene regularly to
prepare for the trips. Preparation will include training sessions, group meetings and fundraising
events. 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
ABP before you apply. Should you have any questions during the application process, please
contact Jessica Gagne Cloutier at 603-358-2665 or jcloutier1@keene.edu.
Thank you for applying!
KSC Alternative Spring Break Trips
Important Dates
.
August: ABP participant applications released.
September 9 @7pm: AB Information Session, Student Center, Atrium Conference Room
September 10 @ 7pm: AB Information Session, Student Center, Atrium Conference Room
September 11 @ 7pm: AB Information Session, Student Center, Atrium Conference Room
October 10: ABP participant applications due.
October 17: ABP teams announced via email.
October 24: Payment 1 due
ABI: $450 due at 4:00 p.m.*
Domestic AB: $225 due at 4:00 p.m.*
November 6: Margarita’s Restaurant Noche Fundraiser night for ABP
November 21: Payment 2 due
ABI: $450 due at 4:00 p.m.*
Domestic AB (Winter Only): $225 due at 4:00 p.m.*
January 30: Payment 2 due
Domestic AB (Spring Only): $225 due at 4:00 p.m.*
*Upon acceptance, participants are required to submit their first payment no later than October
24, 2014 by 4:00 p.m. in person to Stacy Mackenzie on the third floor of the Student Center.
Only cash, checks and money orders will be accepted. Please do not mail any form of payment
and make checks payable to Keene State College. THERE ARE NO REFUNDS.
Turn in completed applications* to Jessica Gagne Cloutier, Coordinator of Community
Service by 4:00 p.m., Friday, October 10, 2014.
*Completed applications must include filled out medical form, waiver, and alcohol and drug
free pledge*
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: ________________________________________________________________
ABI: Do you have a passport?* Yes
No
(Current possession of a passport is not required for application. If you currently have a
passport, please note that it must be valid six months after January 15, 2016.)
*A valid passport is required for international travel. If you do not currently have a passport, the
application process will be discussed at the first participant meeting.
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
Essay Questions
All applicants must answer questions 1-7 to be considered for an ABP 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 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
3 typed pages.
1. Why do you want to participate in an Alternative Break?
2. What can you contribute to an Alternative Break team?
3. What motivates you to be of service to others? Please share experiences or values that
support your response.
4. What causes are you passionate about, and why?
5. Think about your personal experience and understanding of social justice; what are the
characteristics of a just society?
6. Describe an experience when you were pushed beyond your comfort zone. How did you
handle the experience?
7. Please rank the trips below in order of preference where 1= your first choice. Rank only those
trips in which you would like to participate. For full descriptions of each trip, please visit:
http://tinyurl.com/c2qp4hv.
DOMESTIC WINTER TRIPS: DECEMBER-JANUARY
_____ Dec: Urban Education
_____ Jan: Pediatric Healthcare
ALTERNATIVE BREAK INTERNATIONAL
_____Jan: Clean Water & Sanitation
DOMESTIC SPRING BREAK TRIPS: MARCH
_____ Poverty & Racism
_____ Pediatric Healthcare
_____Disaster Relief
_____ Affordable Housing
_____ Farm Workers’ Rights
_____ Rural Healthcare
_____Hunger and Homelessness
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: ___________________________