Personal Information

First Name:

Last Name:

School:

Address:

Address 2:

City:

Contact Information:

Home Phone:

Cell Phone:

E-mail:

Advisor:

How many years have you been an advisor (total, including this year)?

What grade levels?

Teacher:

How many years have you been a teacher (total, including this year)?

What grade levels?

Have you been active in student leadership programs?

Yes No

If so, which organizations?

Have you attended a Leadership Across America Conference before?

Oh, yes! No, it's my first time.

If so, where and when?

Emergency Contact Information:

Contact Name

Contact Phone Number

Are you currently taking medication?

Yes No

List Medications, if any:

List allergies, if any:

Special Health Concerns

Special Housing Concerns

Advisor/Parent Convention Responsibilities:

• Chaperone students to, from, and during convention. (Remain on site during convention hours)   (An adult advisor/chaperone from students’ school MUST accompany all students to the convention)
• Advisors are responsible for the onsite registration of their group upon arrival at convention.
• Arrive on time to all General Sessions & meetings, making certain students arrive on time and attend all sessions as well. Sit in General Sessions with own delegation and supervise their students.
• Monitor behavior of their students and correct inappropriate behavior. (No talking during presentations or interfering with others’ ability to participate; keep students positive in behavior.) 
• Direct students to adhere to the convention dress code and instruct any student who chooses to break dress code to change clothing. (See Form 5 for Dress Code guidelines in notebook upon arrival)
• Check to make sure students from their school are picked up by host family at each pick-up time.
• Supervise students at the dinner and party on Saturday evening.

For delegates staying in hotels with school, advisors are responsible for:

• Making hotel reservations prior to arrival.  Check-in upon arrival and checkout once convention is complete at the hotel.
• Having ALL students quiet and in their own rooms at stated curfew to stay for remainder of night.
• Insuring that students follow hotel rules and are courteous and respectful to other hotel guests.
• Insuring that NO STUDENTS OF OPPOSITE SEX are permitted in the rooms of other students, unless an advisor/chaperone is present in the room. (Violators will be asked to leave convention at own expense.)

Advisors will have opportunities to:

• Enjoy a delectable dinner Friday evening!
• Attend exciting General Sessions 
• Attend the very important group workshop sessions
• Have fun at the dinner and party on Saturday night!
• Make new friends!

NOTE: We are seeking advisors who are willing to lead sessions.  Please volunteer to share what you know with other advisors—Yes, YOU DO have a lot to share!

• Sessions will be a brief 30 minutes each.
• All advisor sessions will occur at the same time.
• Advisors will rotate through sessions, attending 2-3 sessions (exact number to be determined)
• Have fun at the dinner and party on Saturday night!
• Anticipate 12-15 advisors in each session

I have read, understand, and agree to perform the Advisor's Responsibilities as listed above on the form.