2019 Michigan Volunteer Registration

Transcription

1 This form must be printed, filled out completely, and returned as described below. Thank You Michigan Volunteer Registration Contact Information Name: Street: City, State & Zip: Mobile Phone: Home Phone: Retreat Schedule New Participant Reunion July May August 4-6 July 14 August August August 25 Please see sections below for details I Want to Be A (Choose One) Fishing Volunteer Land Volunteer New Participant Retreats Location & Time: Gates Au Sable Lodge, Grayling, MI. Sunday, 12:00 pm until Tuesday, 3:00 pm Choice (Only 2) Attending Need Commitment Dates 1st 2nd All Day 1 Day 2 Day 3 Accommodation Fee Sun, July 14 Tue, July 16 $35 Sun, Aug 4 Tue, Aug 6 $35 Sun, Aug 25 Tue, Aug 27 $35 *** No Charge if Day Only and Accommodations are NOT needed. Total $ Reunion Retreats Retreat Durations and Locations Vary Retreat Attending Need Commitment Dates Location All Day 1 Day 2 Day 3 Accommodation Fee*** Fri, May 10, 3:00 pm to Sun, May 12, 11:00 am Lovells, MI $100 Sunday, July 14, 9 am - 3 pm Gates Lodge N/A $10 Sun, Aug 11, 12:00 pm to Tue, Aug 13, 12:00 pm Gates Lodge N/A $150* *Separate Payment Sunday, Aug 25, 9 am - 3 pm Gates Lodge N/A $10 *** No Charge if Day Only and Accommodations are NOT needed. Total $ For Internal Use Only Status NP RR Confirmed Paid Attended Reeling & Healing Midwest ATTN: C Sero, Coordinator Page 1 of 3 Phone: / Fax: ReelingandHealing.org / FishOn.org info@reelingandhealing.org info@fishon.org

2 Notes About Retreats This form must be printed, filled out completely, and returned as described below. Thank You. What you need to know regarding our retreats when completing the retreat selections on the previous page: There are four general volunteer roles: 1) 2-1/2 Day Land volunteer, 2) 2-1/2 Day Fishing volunteer, 3) One-Day Land volunteer and 4) One-Day Fishing volunteer. Volunteer roles are assigned based on volunteer s skill set and availability. Ideally, volunteers are competent trout fly fishers and able to participate in land activities. Volunteer openings are limited and filled on a first come/first serve basis. New Participant Retreats span three days. If you choose to volunteer for an entire retreat, please choose All. Reunion Retreat length varies based on the retreat. If there isn t a checkbox under a given day, it is either not available or not applicable. Volunteers attending an entire retreat are provided their own bed and may share a room with fellow volunteers of the same gender. As housing is limited at the retreat location, accommodations may be onsite or located off-premise. Some volunteers secure their own lodging, have cabins, or pitch tents. If other lodging options are preferred, volunteers are encouraged to make their own arrangements, at their own expense, and consider staying offsite versus at Gates. All meals, beverages and accommodations are provided to 2-1/2 day volunteers. Breakfast, lunch, and beverages are available for day volunteers. The Commitment Fee is only necessary for those who are attending the entire retreat. If volunteering for an entire New Participant retreat (2-1/2 days), individuals are limited to a maximum of two per season. There are no limits on the number of Reunion Retreats an individual may volunteer at per season. Volunteer Guidelines, Requirements and Registration To be considered as a Volunteer for a New Participant Retreat or Reunion Retreat you are required to: 1. Be 18 years or older. 2. Satisfy or exceed the physical requirements for volunteering at specific retreat location(s). Please refer to the Health Release Form for details. Should physical capability change prior to a retreat, the volunteer must notify the Retreat Coordinator four or more days prior to retreat or risk forfeiting their current and future retreat opportunities. 3. Sign-up and participate on an individual basis. No spouse, significant other, caretaker, family member, friend, pet, etc., may attend the retreat with you in any capacity, or be at the retreat location for any portion of the retreat, or have lodging at the retreat location. No Exceptions. 4. Volunteers are responsible for purchase of a fishing license (if guiding). 5. Volunteers are responsible for their transportation to and from the retreat location(s). Carpooling is encouraged. 6. Complete and submit all six (6) pages of the Volunteer Registration Packet consisting of: Volunteer Registration Form (3 Pages / this document) Health Release Form (1 page) Volunteer Information & Waiver Form (2 pages) 7. Return the Registration Packet with applicable Commitment Fee. 8. Agree and understand Reeling and Healing Midwest may exercise the right to deny attendance, restrict participation or request your departure from a retreat at anytime. 9. Review and sign the following Registration & Cancellation Policy. Reeling & Healing Midwest ATTN: C Sero, Coordinator Page 2 of 3 Phone: / Fax: ReelingandHealing.org / FishOn.org info@reelingandhealing.org info@fishon.org

3 This form must be printed, filled out completely, and returned as described below. Thank You. More About Volunteering! Save Our Contact Info Registration, Payment Options & Cancellation Policy A completed Registration Packet is required to be considered to volunteer. Confirmation will be made by or phone by the Retreat Coordinator. A Commitment Fee is required to validate your attendance at the retreat(s) the Retreat Coordinator confirms for you. We accept payment via check or credit card. Please see details below. Commitment fees are non-refundable for confirmed registrations. Cancellation policy exists due to pre-retreat expenses. Reeling & Healing Midwest reserves the right to assess a cancellation fee for cancellations made 3 days or less prior to the retreat s start date or for failure to attend. AUGUST REUNION RETREAT ONLY: If volunteering for multiple retreats, please send a separate payment for this retreat. This will aid in processing and handling any changes and/or cancellations. Your understanding is appreciated. Pay by Check Please include your check(s) with this Registration Form. Your check(s) will be deposited after you have been confirmed to attend and volunteer. Make check payable to: Reeling & Healing Midwest Mail to: Reeling & Healing Midwest ATTN: C. Sero / Coordinator Pay by Credit Card Agreement and Signature Once you are confirmed for your retreat(s), we ll send an with a link to pay by credit card online. Payment must be received within 2 days of confirmation or 14 days prior to your retreat date, whichever is earlier. Please submit payment only after you have received your official confirmation. Payments submitted without confirmation will be not refunded. I have completed the above information and acknowledge it true. I acknowledge that I am a voluntary participant and I agree to assume responsibility for myself. I further agree to waive any claims against Reeling & Healing Midwest, its officers, employees, agents or volunteers resulting from any and all losses, damages, costs and expenses that are caused by or arise out of any act, omission, default, negligence or other misconduct by Reeling & Healing Midwest in connection with this participation. I acknowledge that the Reeling & Healing Midwest volunteers are not providing medical or psychological diagnosis, treatment, opinions, referrals, guidance, assistance, or counseling for me specifically and that these volunteers are present for the purpose of facilitating involvement and not to provide professional services to group participants. I understand that reasonable measures will be taken to safeguard the health and safety of all participants and that my emergency contact will be notified as soon as possible in case of an emergency. In the event they cannot be reached, I hereby authorize Reeling & Healing Midwest to acquire medical treatment for me. I agree that the statements made on this application are true. I understand misrepresentation or omission of facts requested is cause for dismissal of my request as a Reeling & Healing participant. If appointed as a participant, I agree to adhere to the general policies and guidelines set forth by Reeling & Healing Midwest and to fulfill my participant responsibilities to the best of my ability. I hereby grant to Reeling & Healing Midwest, its agent or assigns, my permission to use my first name, any and all pictures, photographs of or news stories about me for reproduction in any form but not limited to, advertising, illustration, television, or scientific publication. - By signing below, I acknowledge I have read, understand, and meet all applicable participant requirements, payment options, obligations, and cancellation policy. Signature Print Date Reeling & Healing Midwest ATTN: C Sero, Coordinator Page 3 of 3 Phone: / Fax: ReelingandHealing.org / FishOn.org info@reelingandhealing.org info@fishon.org

4 This form must be printed, filled out completely, and returned as described below. Thank You Volunteer Information & Waiver Form Contact Information Name Street Address City, State & Zip Code Home Phone/Cell Phone Work Phone Address Skill Inventory Circle or add relevant information where appropriate. Please note that lack of any skill(s) listed below does not disqualify you from volunteer opportunities. I AM I HAVE I CAN Circle à Comfortable setting up your fly fishing equipment and fishing on your own? Open to learning new fishing skills, enhancing your knowledge, or sharing your expertise with others? Comfortable wading and navigating an unfamiliar river? Capable of safely wading & shadowing a novice fly fisher and/or non-swimmer? Currently certified in CPR, First Aid, Wilderness First Aid, Medical Profession, Food Sanitation, Social Work or other relevant area? Studied the mechanics of fly casting through related books, videos, classes or workshops? Received fly fishing instruction in any of these areas: On-stream Fly Presentation, River Ecology, Fly Tying or Catch & Release? (circle relevant areas) Instructed others (outside of family members) in any aspect of fly fishing? Prior corporate catering, event planning or hotel experience? Describe the life cycles of mayflies, caddisflies and stoneflies? Demonstrate how to 1) Set-up a rod and reel; 2) Utilize a loop-to-loop; 3) Rebuild a leader? Confidently tie a 1) Clinch knot; 2) Double Surgeon s knot; 3) Perfection Loop; 4) Nail knot Describe how to 1) locate trout in a river and 2) describe a riffle, run and pool? Explain 1) the difference between a dry fly, wet fly and streamer and 2) how to fish with them? Confirm you meet or exceed the physical requirements detailed on the Health Form? Describe your casting skill level/proficiency as: 1) Novice; 2) Comfortable in Most Situations; or 3) Self Described Expert. Page 1 of 2 P: / E: info@fishon.org ReelingandHealing.org or FishOn.org 2019

5 This form must be printed, filled out completely, and returned as described below. Thank You Where to Help Check all areas where you would like to contribute. Fishing Volunteer Non-Fishing Volunteer One-Day Volunteer 2-1/2 Day Retreat Reunion Retreat Carpooling Participants Pre-Retreat Organizing Onsite Retreat Coordination Post-Retreat Organizing Grocery/Supply Shopping Equipment Coordination Equipment Maintenance Fly Fishing Instruction Entomology Instruction Knot Tying Instruction Participant Recruitment Volunteer Recruitment Other Describe: Fly Fishing It is not required, but do you have any previous experience? Please describe: Do you have your own equipment? YES or NO Will you need to borrow any equipment? YES or NO If you need waders please provide: Shoe Size Hip Measurement Height Previous Volunteer Experience or Cancer Experience Summarize your previous volunteer and/or cancer experience. Other Notations Do you have any physical restrictions and/or special needs? Do you have any allergies? Chronic health issues? Are you presently taking any medications? If yes, please list: Birth Date: Month Date: TYPE of Sleeper: LIGHT EARLY RISER HEAVY SNORE APNEA/MACHINE/OTHER What was the date of the last Reeling & Healing Midwest retreat you attended? Any other information for us to know? Page 2 of 2 P: / E: info@fishon.org ReelingandHealing.org or FishOn.org 2019

6 This form must be printed, filled out completely, and returned as described below. Thank You Retreat Information Health Release Form For Use by ALL Volunteers and Reunion Retreat Participants Retreat Date(s) / / Retreat Location(s) Retreat Attendee s Full Name: Medications Allergies Chronic Issues (i.e. Diabetes, HBP, etc) Physical Restrictions and/or Needs Emergency Contact Name: Physician Information Dear Physician, Phone: The patient named above has applied to attend a One or Two and one-half day retreat as a Participant or Volunteer. The retreat is conducted by Reeling & Healing Midwest, a non-profit organization that provides fly fishing wellness retreats for women recovering from cancer. Attendees are eligible to attend if physically capable to meet the criteria. Please complete, sign and return this form to the address or fax below. If you have any questions, phone I acknowledge the named patient is a reasonable candidate to participate/volunteer and meets the criteria checked below. Physician Signature Date / / Print Name & Title Phone Address Physical Requirements and Signature Instruction for Participant or Volunteer: Please check the appropriate box below and initial. PARTICIPANT Without assistance, participant must be able to ascend and descend stairs, climb up and down an outdoor trail and river/stream bank, wade comfortably with stability for extended periods of time in a river or stream, and be capable of walking by self on even and uneven terrain. Participant will need to tolerate sitting or standing for periods of time, lift and cast a fly rod, and verbally communicate needs. VOLUNTEER - Volunteer must be able to ascend and descend stairs several times per day, climb up and down an outdoor trail and river/stream bank, wade comfortably with stability for extended periods of time in a river or stream, capable of walking by self on even and uneven terrain, able to sit or stand for periods of time, lift and cast a fly rod, have good verbal and non-verbal communication skills, lift and move objects and boxes from 5lbs-40lbs through the duration of the retreat, and securely assist and, if guiding, support an individual of up to 165lbs in the river. OPT OUT: I acknowledge I am a reasonable candidate to participate as a participant or volunteer at a Reeling & Healing Midwest retreat and have opted to not obtain my physician s authorization. I understand RHM reserves right to request physician approval at any time, access my abilities onsite, and limit/prohibit participation as necessary. Attendee Signature Date / / Submitting Form One of the following methods may be used to return the completed form: Mail: Reeling & Healing Midwest Scan/ info@fishon.org or info@reelingandhealing.org c/o Retreat Coordinator (Sero) Fax: N. Dearborn, P.O. Box 10469, P: / E: info@fishon.org ReelingandHealing.org or FishOn.org 2019