Greetings!
Enclosed you will find information, application, and release forms for Phase I of the
Jackson Hole Leadership Program, 2015. Please return completed application to the Van
Vleck House office (510 S. Cache between Karns and Snow King) on or before June 12th
with a $50 non-refundable deposit to secure your child’s spot in the session they desire.
Checks can be made out to “Teton Youth and Family Services.” Forms can also be mailed
to:
VAN VLECK HOUSE
JHLP
PO BOX 2631
JACKSON, WY 83001
Price: Phase I (10- to 12-year-olds): $250
The full payment balance is due on the first day that your child attends JHLP. Many
scholarships are available upon request, and we aim to serve all children with an interest in
participating. Please do not hesitate to apply, regardless of financial situation. If you
would like to donate money to the program or help pay for another child to attend camp
this summer, please include your donation with your deposit. Your generosity is invaluable
to us.
Thank you for taking the time to thoroughly read this packet with your child. We ask that
participants be able to attend every day of the session they select. If this is not possible,
please choose a different week that will not interfere with alternate engagements.
We look forward to seeing you this summer!
Ben Jefka and Alex White
JHLP Program Coordinators
Phone: (307) 733-6440
Fax: (307) 733-6374
Email: leadership@tyfs.org
Jackson Hole Leadership Program
Parent Information
Phase I of the Jackson Hole Leadership Program (JHLP) is open to all boys and
girls in Teton County between the ages of 10 and 12. Through a variety of fun
experiences in the outdoors, we aim to foster values of self-confidence, teamwork
and positive decision-making to aid participants through their experiences in
adolescence. JHLP operates on a “Challenge by Choice” philosophy, allowing
campers to take risks they are comfortable with in a safe context.
Program Leaders
Ben Jefka has a background in environmental and experiential education. He has
taught and guided in the outdoors for eight years as well as working for the Van
Vleck house for almost seven years. He is looking forward to spending as much
time as possible out in the woods this summer.
Alex White is excited to head into his sixth year with the Leadership Program.
In 2013 he started a Master’s program in Professional Counseling through Prescott
College in Arizona. It has certainly been a balancing act to manage work, school,
and play, but it has all been greatly rewarding. Needless to say, Alex is excited for
a break to spend time in the outdoors with another great group of JHLP
participants, laughing, joking and playing Mafia around the campfire.
Jane Strader is the newest member of the JHLP team. She comes to us fresh out
of the graduate education program at the Teton Science Schools. This is her
second summer in Jackson Hole, and she looks forward to chasing her “Calvin and
Hobbes” dreams by playing, imagining, and exploring in the outdoors!
All JHLP leaders are CPR certified, have a minimum certification of Wilderness
First-Aid, and have been trained in facilitation and safety at the Doug Walker
Challenge Course, as well as various activities and team-building initiatives.
Enclosed you will find the JHLP application materials. There is a schedule, as well
as three (3) pages of forms to complete, sign, and return. We look forward to an
exciting week with your child. If you have any questions or concerns, please feel
free to call us at the Van Vleck House at (307) 733-6440, or e-mail us at
leadership@tyfs.org.
Jackson Hole Leadership Program
Phase I Information
Pick-up and drop-off will be at Phil Baux Park, at the base of Snow King Mountain
Monday through Thursday
Things to bring EVERY DAY
Small backpack
Lunch
Water!!!
Athletic shoes (no open-toed shoes please!)
Jacket / Raingear
Sunscreen and hat
Monday: Icebreakers, team-building games, and initiatives at Mike Yokel Park.
Tuesday: Low and high ropes initiatives at the Doug Walker Challenge Course at
the Teton Science Schools.
Wednesday: WATER DAY canoeing and kayaking at String Lake (Wear swimsuits
and water shoes).
Thursday: Camping in the Gros Ventre Mountains (Please refer to Camping
Equipment List you will receive on Wednesday).
Friday: Hike in Grand Teton National Park. Return to Mike Yokel Park on E. Kelly
Street for a Closing Ceremony at 4 PM. Parents encouraged to attend!
(Closing Ceremonies generally run around 45 minutes)
Jackson Hole Leadership Program
2015 Youth Application – Phase I (ages 10-12)
Check your 1st, 2nd and 3rd choices and label them accordingly
____ Session 1: June 22-26
____ Session 4: July 27–31
____ Session 2: June 29-July 3
____ Session 5: August 10-14
____ Session 3: July 20-24
____ Session 6: August 24-28
Child’s Name ________________________________________________________________
Gender_______ Age______ Birthday____________ Grade in School (Fall 2015) ____________
Mailing Address______________________________________________________________
Parent/s Name/s_____________________________________________________________
E-mail Address/es____________________________________________________________
Best Contact Phone Number________________ Alternative Phone Number________________
Please Circle “YES” or “NO” to answer the following questions:
Has your child ever spent a night away from home (without parents)?
YES
NO
Does your child know how to swim? (circle one)
YES
NO
Does the youth have any dietary restrictions?
YES
NO
If yes, please explain ____________________________________________________
____________________________________________________________________
____________________________________________________________________
Are there any other concerns you would like to bring to our attention?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
If your child has a history of emotional, behavioral, family or school issues, please discuss them
with a program leader prior to your session so we can best support your child’s needs.
(continued on back)
Participation Consent
I/we, ___________________________, (parent’s name) as parent(s) and/or
guardian(s) hereby give consent for _________________________ (child’s
name) to participate in the Jackson Hole Leadership Program.
I am aware that neither the Van Vleck House, GTNP, BTNF, nor the Jackson Hole
Leadership Program youth leaders will be liable for property destruction, injuries,
or accidents that occur while my son/daughter is involved in any activities that are
related to or sponsored by the Jackson Hole Leadership Program.
__________________________
Parent/Guardian Signature
___________________
Date
I request that my child’s photo NOT be used in future promotions for the Jackson
Hole Leadership Program (program materials, brochures, etc.)
__________________________
Parent/Guardian Signature
__________________
Date
Medical Consent
Consent and permission is hereby given for the Jackson Hole Leadership Program staff to
obtain emergency care including anesthesia, surgery, hospitalization, or other treatment
that may be deemed necessary. I understand that no procedures of an experimental
nature shall be performed under this authorization. I also understand that every
reasonable effort will be made to contact me before medical treatment is rendered.
The Jackson Hole Leadership Program staff carries the following over-the-counter
medications to be used as necessary with the above-mentioned program participant:
Ibuprofen, Benadryl, Children’s Pepto Bismol, Imodium A-D, and Claritin. All medications
will be used as directed by the manufacturer. If you would prefer that your child not be
administered any of these medications, please inform Jackson Hole Leadership Program
staff.
Please note on the back side of this page if your child has any allergies or has medications
to be administered by staff during the duration of the Jackson Hole Leadership Program.
Emergency Contacts (other than parents)
Name______________________________________
Phone___________________
Name______________________________________
Phone___________________
Name______________________________________
Phone___________________
Is youth limited to any physical activity?_______________ If yes, please explain:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
(continued on back)
Allergies: Please list all allergies, mild or serve, that your child experiences
(medications, foods, bites, stings, etc.).
Allergy
Reaction
Medication
Medications: Please list all medications that your child is currently taking,
including over-the-counter or homeopathic medications.
Medication
Dosage
Condition
Side Effects
Parent Signature _____________________________ Date ______________