14-2 amya complete application

Department of Military and Veterans Affairs

Alaska Military Youth Academy

P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

LAST MINUTE APPLICATION INSTRUCTIONS Thank you for your interest in the Alaska Military Youth Academy. Our next cycle, Spring Cycle-class 2014-2, begins April 1, 2014. AMYA is located on JBER (Joint Base Elmendorf Richardson-just outside Anchorage) Do you qualify?

□ Are you 16, 17, or 18 years of age on April 1, 2014? □ Are you in need of your high school education? (cannot attend if you have a diploma or GED) □ Are you not currently enrolled in high school or GED –or- at risk of not graduating with your peers (behind in

credits, enrolled but not attending, failing out, finding it difficult to learn in a traditional HS setting) □ Are you physically and mentally capable of completing a demanding program.? □ Are you a volunteer participant? This means that you have some desire to attend.

If you are not sure if you qualify, please contact me. AMYA operates two cycles per year, each beginning on or about April 1 and October 1. This program is tuition FREE! APPLICATION PROCESS:

1. LEARN MORE Make sure you have a good understanding of the program. The program and description form describes in detail the program. You can also watch our video at; https://www.youtube.com/watch?v=OUgX0ysPOXQ. Please also find us on facebook https://www.facebook.com/pages/Alaska-Military-Youth-Academy-AMYA/65681283781

2. COMPLETE APPLICATION PACKET (attached). Make sure all forms are complete and organized. USE THE CHECKLISTS!

The application packet includes the medical packet. (The mentor packet should be provided to your mentor to complete- mentor application is due by April 1, 2014.) Submit completed application via scan to e-mail, fax or send your completed application to: Mail: AMYA PO Box 70628, Fairbanks, AK 99707-Fax: 907-374-7969 –or- E-mail: [email protected] –or- BRING TO INTERVIEW (Fairbanks Area): to NG Armory office located at 202 Wien Ave in Fairbanks (corner of 2nd/Wien)

3. INTERVIEW Interviews last 30-45 minutes and are a one-on-one CONFIDENTIAL interview between the applicant (youth) and the admission staff. Youth within driving distance of Fairbanks will participate in an in-person interview. Youth outside reasonable driving distance will participate in a telephonic interview.

https://www.youtube.com/watch?v=OUgX0ysPOXQ

https://www.facebook.com/pages/Alaska-Military-Youth-Academy-AMYA/65681283781

https://www.facebook.com/pages/Alaska-Military-Youth-Academy-AMYA/65681283781

mailto:[email protected]

Don’t Delay! Please note that acceptance is based on first come, first served.

If you are 18 yrs of age or older, you do not require parent/guardian signature (unless you are in states custody) but must complete all forms!

Other Important Information: AMYA can only be attended one cycle, unless the candidate/cadet was excused for medical purposes and the medical issues has been resolved and can be confirmed by a medical professional. Applicants must provide this information which will be reviewed by the PRM Supervisor, Commandant, and medical department. Youth that were terminated for other reasons may request readmission through our commandant. In order to do so, you must provide a current complete application, letters of support, letters of reference and a detailed letter explaining the youth’s desire for reconsideration, and complete another interview with admissions staff. It is important that the youth address the behaviors/reasons for dismissal and the changes, treatment and factors that support the youth’s ability to be successful in the program. You must have a mentor. Your mentor must be at least 21 years of age, same gender and be able to pass a background check. Most importantly, a mentor needs to be someone who you look up to and respect. The mentor must commit to the 18 month program and be someone who will provide guidance and hold you to task. The mentor must complete the mentor application, have references, pass background check, pass screening and participate in a one-time training. The mentor is NOT required to travel to Anchorage! You will be assigned a local Anchorage mentor (volunteers permitting) while you are in the residential portion of the program. If you know someone already in the Anchorage area who would volunteer to be your mentor, please submit mentor application for both Anchorage and your home area. A mentor CANNOT be immediate family; i.e. mom, dad, siblings OR anyone living in the same home. Mentor applications must be received by the start of the cycle and it is preferred that they be turned in at the time of the interview. You may have more than one mentor. Additional mentor applications are available online at www.akmya.org select the mentor tab. You will need a copy of your birth certificate, social security card and photo ID. If you have lost your birth certificate or social security card, you may provide a copy of your replacement request in interim. YOU MUST USE THE CHECKLISTS provided to ensure you have the required paperwork! Please contact me with any questions. I hope you decide you are up for a ChalleNGe! Angela Chapin, Admissions [email protected] Alaska Military Youth Academy PO Box 70628, Fairbanks, AK 99707 Phone 907-374-7960, Fax 907-374-7969 Find us on Facebook;http://www.facebook.com/pages/Alaska-Military-Youth-Academy-AMYA/65681283781

http://www.akmya.org/


http://www.facebook.com/pages/Alaska-Military-Youth-Academy-AMYA/65681283781

http://www.facebook.com/pages/Alaska-Military-Youth-Academy-AMYA/65681283781

http://www.ngycp.org/site/state/ak/

AMYA APPLICATION PACKET-CHECKLIST 1 REVISED 10.8.13

ALASKA MILITARY YOUTH ACADEMY Anchorage Admission Office 800 East Dimond Blvd., Suite 3-229 - Anchorage, AK 99505

Phone: 907.375.5554 or 907-375-5556 Fax: 907.375.5557 Satellite Admission Office Mail: PO Box 70628 Fairbanks, AK 99707 Physical: 202 Wien Ave. Fairbanks

Phone: 907.374.7960 Fax: 907.379.7969

Application Packet Checklist If you do not have everything required (bolded items), you will not be interviewed!

If the applicant is 18 years of age, parent/guardian signature is not required. Applicant must still complete all forms and sign for themselves.

□ Alaska Military Youth Academy Student Application-Basic Information □ 100 word statement on why you want to attend the academy □ PGIS- Parent Guardian Information Sheet (JBER ACCESS FORM)/Also serves as visitation list

□ Program Description and Waiver □ Notification of Transportation Responsibility (21 day notice) □ Parent Support Contract □ Model Consent and Release of Information □ Release of Information □ *Free from Adult Level Felony (*required for any youth with current DJJ involvement) □ Internet User Student Agreement □ Request Letter for Transcripts & Education Records (1 submitted to current/last school and 1

remains with application packet) □ Alaska Power of Attorney (*Must be Notarized-must be signed in the presence of a notary) □ Medical Power of Attorney (*Must be Notarized- must be signed in the presence of a notary)

*Rural Villages that do not have notaries may use the local postmaster pursuant to AS 44.50.180. □ Medical Packet (Medical Packet has its own checklist-please be sure to bring to your interview) □ Mentor Application Packet- please provide to your prospective mentor

(Must be submitted by the start of the cycle, preferably at time of interview) □ Copy of Birth Certificate (if you cannot find yours, request copy and provide request- upon receipt of

original birth certificate-provide copy to AMYA ASAP.) □ Copy of Social Security Card (if you cannot find yours, request copy and provide request- upon receipt

of SS card-provide copy to AMYA ASAP.) □ Copy of a valid State or Military Dependent ID, passport and/or BIA card (if applicable). ID must have

photo! Those eligible for services through the Alaska Native Medical Center must contact 907-563-2662 and register for medical services.

□ Proof of Custody (if under 18 must provide proof of custody if shared, adopted, under power of attorney or in the custody of state or other entity).

□ A copy of the applicant’s immunization records which complies with the State of Alaska Immunization Regulations (medically verified/signed by licensed healthcare provider.)

□ A current TB test taken within the past six months Applicants with previous positive PPD test will need follow-up with their healthcare provider for TB symptom review and clearance (written clearance required) Results can be transcribed to Physical Examination Form

□ A copy of any current eyewear prescription (within 1 yr). Applicants will need 2 pair of eyeglasses upon arrival at AMYA, contact lenses are NOT permitted

□ Females must have a natural colored hair. All youth must remove all piercings prior to attending AMYA.

achapin

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AMYA APPLICATION PACKET-Basic Information 2 REVISED 10.8.13

ALASKA MILITARY YOUTH ACADEMY

APPLICATION-Basic Information; Applicant is the youth applying for admission who may also be referred to as candidate or cadet.

APPLICANT’S NAME: (last) ______________________ (first) ______________________ (middle) __________

APPLICANT’S E-MAIL: _____________________________________________________

APPLICANT’S MAILING ADDRESS: (Street/PO Box): _________________________________________________

CITY: _________________________________________ STATE: _______________ ZIP: ________________

HOME/ PRIMARY Ph#: ( ) _______-_________ APPLICANT CELL#:( ) _______-_________

SOCIAL SECURITY #: ______-_____-________ U.S. Citizen: Yes ____ No ____--> Must be US Citizen to Qualify

DATE OF BIRTH: MMDDYY _____/_____/_____ Age:* ______ Gender: ___________

*Must be between the ages of 16-18 on the start date of the cycle-no exceptions

HEIGHT: _______ WEIGHT: ________ HAIR COLOR**: ____________ EYE COLOR: __________

**FEMALES: IF YOUR HAIR IS DYED AN UNNATURAL COLOR IT MUST BE RETURNED TO A NATURAL COLOR PRIOR TO ATTENDING AMYA

ETHNICITY: (CIRCLE ALL THAT APPLY) ASIAN - BLACK - ALASKA NATIVE - CAUCASIAN - HISPANIC - NATIVE AMERICAN - PACIFIC ISLANDER - OTHER (SPECIFY): __________

LIST YOUR SIBLINGS NAMES/AGES: _____________________________________________________________

__________________________________________________________________________________________________

DO YOU HAVE ANY TATTOOS? NO___ YES ____ IF YES, PLEASE INDICATE WHAT THE TATTOO(S) IS/ARE AND

LOCATION(S): ______________________________________________________________________________

ALLERGIES: ________________________________________________________________________________

CURRENT MEDICAL DIAGNOSIS: _______________________________________________________________

CURRENT MEDICATION AND RELATED CONDITION: ________________________________________________

__________________________________________________________________________________________

TREATMENT PROGRAMS (NAME AND TYPE)/REASON FOR & DATES OF ATTENDANCE/OUTCOME (COMPLETE,

DISCHARGED NON-COMPLIANT ETC): _____________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


DO YOU HAVE A HIGH SCHOOL DIPLOMA OR GED?: NO___ YES ___ IF YES, YOU ARE INELIGIBLE FOR AMYA HAVE YOU EVER BEEN CONVICTED OF A FELONY? NO___ YES____ (CIRCLE) JUVENILE OR *ADULT *IF ADULT FELONY, YOU ARE INELIGIBLE FOR AMYA

ARE YOU CURRENTLY ON PROBATION? NO___ YES___ PROBATION OFFICER: _________________________ PROBATION OFFICER PHONE#: ( )_____-________ MUST SUBMIT COPY OF YOU PROBATION CONDITIONS, DISPOSITION/ADJUDICATION ORDER, HIA AGREEMENT OR INFORMAL PROBATION AGREEMENT, YOUR JPO MUST ALSO COMPLETE THE FELONY DECLARATION FORM. YOU MUST ALSO SUBMIT A DJJ CONSENT TO RELEASE FORM FOR AMYA.

DO YOU CURRENTLY HAVE AN OCS WORKER? NO___ YES___ NAME OF WORKER: _____________________ CASE WORKER’S PHONE#: ( )_____-________ PLEASE COMPLETE OCS CONSENT TO RELEASE FORM FOR AMYA

PARENT/GUARDIAN INFORMATION: IF UNDER 18, WHO HAS LEGAL CUSTODY (EXPLAIN IF NECESSARY)?: _______________________________________ (MUST PROVIDE PROOF OF CUSTODY IF SHARED, ADOPTED, UNDER POWER OF ATTORNEY OR CUSTODY OF STATE OR OTHER ENTITY) PLEASE COMPLETE INFORMATION BELOW, REGARDLESS OF WHETHER YOU ARE 18. INCLUDE STEP-PARENTS AS WELL AND USE THE BACK OF THIS FORM SHOULD YOU NEED MORE ROOM. (1) PARENT/GUARDIAN NAME: _______________________________________________________________

RELATIONSHIP TO APPLICANT: __________________EMAIL ADDRESS: ________________________________ PLEASE NOTE THAT E-MAIL IS THE PRIMARY FORM OF COMMUNICATION FROM AMYA STAFF

MAILING ADDRESS: __________________________________________________________________________ CITY: _________________________________________ STATE: _______________ ZIP: ________________

HOME #: ( )______-_________ WORK #: ( )______-_________ CELL #: ( )______-_________

(2)PARENT/GUARDIAN NAME: ________________________________________________________________



HOME #: ( )______-_________ WORK #: ( )______-_________ CELL #: ( )______-_________




HOME #: ( )______-_________ WORK #: ( )______-_________ CELL #: ( )______-_________




HOME #: ( )______-_________ WORK #: ( )______-_________ CELL #: ( )______-_________


EMERGENCY CONTACT INFORMATION: (SOMEONE OTHER THAN YOUR PARENTS/LEGAL GUARDIAN(S))

NAME: ________________________________________________________________


MAILING ADDRESS: __________________________________________________________________________

CITY: _________________________________________ STATE: _______________ ZIP: ________________

HOME #: ( )______-_________ WORK #: ( )______-_________ CELL #: ( )______-_________

PROSPECTIVE MENTOR INFORMATION: APPLICANT MUST HAVE A MENTOR. MENTOR MUST BE ATLEAST 21 YEARS OF AGE, ABLE TO PASS BACKGROUND CHECK, CANNOT BE IMMEDIATE FAMILY (MOM, DAD, SIBLINGS) OR SOMEONE LIVING IN THE SAME HOUSEHOLD. MENTOR MUST BE ABLE TO COMMIT TO PROGRAM REQUIREMENTS. PLEASE PROVIDE MENTOR PACKET TO YOUR PROSPECTIVE MENTOR. Mentor application are due on or before the start of the cycle. PROSPECTIVE MENTOR’S NAME: _______________________________________________________________

HOW DO YOU KNOW THE MENTOR?: ___________________________________________________________

EMAIL ADDRESS: ________________________________

PLEASE NOTE THAT E-MAIL IS THE PRIMARY FORM OF COMMUNICATION FROM AMYA STAFF

MAILING ADDRESS: __________________________________________________________________________

CITY: _________________________________________ STATE: _______________ ZIP: ________________

HOME #: ( )______-_________ WORK #: ( )______-_________ CELL #: ( )______-_________

I fully understand that the Alaska Military’s ChalleNGe Program will be physically and mentally demanding. I VOLUNTARILY accept the challenge. I understand that the Alaska Military Youth Academy does not provide day care for dependents. To the best of my knowledge, all statements made by me on this application are true. I further understand that the information I have given in this application and the documents attached hereto are subject to verification and that I may be disqualified from attending the Alaska Military Youth Academy if it is determined that the information I have provided is false.

APPLICANT SIGNATURE _______________________________________ DATE _______________

PARENT/GUARDIAN SIGNATURE________________________________ DATE _______________

Applicant Statement

Applicant’s Statement (100 words or more) on

“Why I want to attend the Alaska Military Youth Academy”

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By signing below you are certifying that;

I understand the Alaska Military Youth is a voluntary program and I am choosing to apply.

APPLICANT SIGNATURE _______________________________________ DATE _______________

AMYA APPLICATION PACKET-PGIS 5 REVISED 10.8.13

PARENT/GUARDIAN INFORMATION SHEET (JBER ACCESS FORM and FAMILY VISITATION LIST) (THIS IS TO BE COMPLETED BY PARENT/GUARDIAN)

CADET NAME: __________________________________ *PLATOON#: _______ (*PLATOON WILL BE ASSIGNED NEAR START OF CYCLE)

Please provide the names of family members you wish to be allowed to visit your Cadet while attending the Alaska Military Youth Academy. This must be limited to IMMEDIATE FAMILY MEMBERS- include yourself, other parents/guardians, siblings and grandparents- anyone other than this must be approved by the Cadet’s platoon leader and should not be added below unless approval has been granted. Contact the Team Leader’s Center or TLC at 907-384-6040 for more information. This information is required to allow us to meet the security regulations of the JBER military installation on which AMYA resident. We attempt to expedite your entry onto the base for scheduled visits. Failure to provide this information may or will lead to refusal for entry at the gate, or your need to go in to the Visitor Center. DL/SI (driver’s license or state ID not required for youth under 16. **SSN- Social Security Number. Last Name First Name MI Relationship to

Cadet Age Date of Birth

(mm/dd/yyyy) Phone# DL#/State SSN-last

4 only

AMYA APPLICATION PACKET-Program Description and Waiver 6 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

PROGRAM DESCRIPTION & WAIVER

1. PURPOSE

The purpose of this statement is to provide to applicants, candidates, cadets, as well as their parents and guardians, a full and complete description of the nature of the National Guard Youth ChalleNGe Program conducted by the Alaska Military Youth Academy. 2. GENERAL

a. The ChalleNGe Program is a federal/state partnership program. It is under the auspices of the National Guard. Each state which chooses to participate in the program administers and oversees its own program. The mission of the National Guard Youth ChalleNGe Program is to intervene in and reclaim the lives of at-risk youths and produce Program Graduates with the values, skills, education, and self-discipline necessary to succeed as adults

b. The ChalleNGe Program is not a traditional school. It is a 17 ½ month program that includes two phases. First is the Residential Phase which consists of a two week (11 – 14 day) on campus in-residence period referred to as the Acclimation Period in which candidates are being assessed for their ability to participate in the remaining portion of the residential phase. Candidates officially receive cadet status on successful completion of the first two weeks. The Acclimation Period is immediately followed by the duration of the ChalleNGe Period which consists of a 20 ½ week on-campus program. After graduation from the residential phase, Cadets embark on the second phase, which is a 12 month Post-Residential Phase conducted off campus in the Cadet’s hometown or other location.

c. Participation in the ChalleNGe Program is by invitation and is totally voluntary. No youth is required to attend, and no parent or guardian is required to send their child.

d. The ChalleNGe Program is not a basic training program or a “Boot Camp.” The ChalleNGe Program does utilize many techniques, such as the buddy system, marching, organized physical training, and leadership positions, that are successfully used by the military to build teams, train individuals, and instill personal and group responsibility. The ChalleNGe Program focuses on “Eight Core Components” to achieve overall success. The “Eight Core Components” are:

1. Academic Excellence; 2. Physical Fitness: 3. Job Skills; 4. Service to Community;

5. Health and Hygiene; 6. Responsible Citizenship; 7. Leadership/followership; and 8. Life Coping Skills.

e. ChalleNGe Program’s criteria require Candidates/Cadets be at least 16 years of age on the first day of the

program’s Acclimation Period. Candidates/Cadets must be residents of the State of Alaska, must not have graduated from high school, and not be currently attending high school, must be unemployed, must be drug free, must not be on parole or probation for other than juvenile status offenses, must not be indicted or charged with a criminal offense, and must not have a felony conviction or conviction for a capital offense.

f. Candidates/Cadets must be physically and mentally able to participate in all aspects of the ChalleNGe Program. The Academy executes both scheduled and random drug tests to insure Candidates/Cadets are and remain drug free.

g. The Alaska Military Youth Academy can remove Candidates/Cadets from the program for failure to meet the standards of the Eight Core Components or for other reasons which include, but are not limited to the following:


breaches of law or breaking the rules of the Academy, drug positive test results, danger to self or others, failure to adapt to the requirements of the ChalleNGe Program, or failure to successfully meet the graduation requirements of the “Eight Core Components”.

h. A major function of the Academy is to ensure and provide a safe environment for all Candidates/Cadets. This includes treating all Candidates/Cadets as individuals deserving of respect. The Academy has a strict “Hands Off” policy under which Staff and Cadre are prohibited from physically touching a Candidate/Cadet for reasons other than for “necessary or common touch.” “Necessary touch” includes, but is not limited to, touching necessary to render first aid or save a life, and touch to prevent injury to a Candidate/Cadet from themselves or another. “Common touch” includes, but is not limited to the following, a common hand shake, congratulatory “pat on the back”, or touch to correct or fix a uniform deficiency after asking and notifying the Candidate/Cadet.

i. The ChalleNGe Program is a high intensity program that places a high degree of physical and mental demands on the Candidates/Cadets. Because of the intense nature of the program Candidates/ Cadets will have limited contact with their parents/guardians. Candidates/Cadets will also have limited contact with other outside personal contacts, except for their assigned mentors. 3. THE ACCLIMATION PERIOD

a. The Acclimation Period of the program is a two week (11 – 14 day) high intensity, on-campus, residential phase focused on building the Candidates’ self image, confidence, and individual responsibility. Team building is a major goal of this phase of the ChalleNGe program. This initial phase of the program includes removing distractions from the Candidates (influence of parents, girlfriends, boyfriends, school friends, gangs, television, game boys, I Pods, etc.) and removing bad habits and dependencies (tobacco, poor sleeping cycles, poor eating habits, poor physical fitness habits, junk foods, etc.). Candidates in the Acclimation Period are under the supervision of Cadre personnel 24 hours a day, 7 days a week.

b. Candidates in the Acclimation Period will be engaged in a high intensity physical fitness routine/program within their capability, aimed at improving physical fitness and channeling negative energy. Common physical fitness activities in this phase will include callisthenic exercises as well as cardiovascular events such as running. Individual and group physical fitness activities, such as push-ups may be used to reinforce learning points and objectives while at the same time improve physical fitness.

c. Candidates in the Acclimation Period will have limited physical comforts and amenities. Living conditions are akin to camping out. Candidates will be housed in heated tents or rudimentary buildings, and will sleep on ground pads in sleeping bags. Most, if not all, meals will be served “field style” and bathroom facilities will often be portable. Showers will be on a scheduled basis to insure hygiene. Candidates earn amenities and comforts such as use of the dining facility, barracks and indoor bathrooms during the course of the Acclimation Period Phase.

d. In the Acclimation Period, the Cadre/Staff begin assisting Candidates in recognizing and reinforcing positive behavior and choices over poor behavior and negative choices. Positive behavior choices are recognized and built upon while negative behavior and choices are positively corrected.

e. The Acclimation Period is used by Cadre/Staff to confirm and build on the Candidate’s commitment to attend and complete the ChalleNGe Program.

f. Candidates often want to leave during the Acclimation Period for a multitude of reasons. It is not uncommon for Candidates to claim the Cadre/Staff physically or mentally abuse them, will not feed them, are mean to then, hate them, or will use some other “hook” to gain a parent/guardian’s support for them to leave the program. Parents/ Guardians need to be aware of these and other tactics used by Candidates to leave the program, and need only to say


“NO” to their Candidate seeking to leave during the Acclimation Period Phase. However, the Academy takes all allegations of mistreatment seriously and will investigate all reported incidents.

g. Candidates who graduate from the Acclimation Period will earn the status of Cadet and will move on to the on campus ChalleNGe Period of the Residential Phase. 4. RESIDENTIAL PHASE

a. The ChalleNGe Period of the Program is an intensive 20 ½ week on-campus residential phase immediately following the Acclimation Period. While this phase continues to build on a Cadet’s positive choices and behavior, individual responsibility, and team building, the ChalleNGe period’s main focus is on the Cadet’s successful completion of the “Eight Core Components” requirements.

b. The Challenge Period consists of a variety of activities intended to create a successful Cadet. Those activities include:

(1). Vocational Activities (Job Skills). This includes community work experience, job shadowing, and vocational training and experience. Vocational activities may include but are not limited to culinary arts, carpentry, aviation/ground equipment repair, computer skills, office skills, etc.

(2). Academic Activities (Academic Excellence), which focus on Cadets completing high school and obtaining a diploma or a GED Certificate. While Academics are given extremely high priority, completion and graduation of the Residential Phase does not guarantee that a Cadet will obtain a Diploma or GED Certificate.

(3). General Education Activities. This includes physical fitness, service to community, health and hygiene, responsible citizenship, leader/followership, and life coping skills. Cadets learn to deal with emotions of anger, grief, and frustration, learn personal financial management, increase self- esteem/discipline, and learn the effects of substance abuse and sexually transmitted diseases on their lives learn the value of proper nutrition, personal hygiene, and physical fitness.

(4). “Green Line” Adventure Training Activities. These activities meet Cadets’ needs for adventure and learning. Activities may include such things as off site trips to an obstacle course, jumping from a “Jump Tower”, rappelling, creek/stream crossing training, fishing, canoeing/boating/rafting, swimming, familiarization rides in military aircraft, hiking, etc.

c. Cadets are required to have a mentor and/or mentors in the Residential Phase. A Cadet without a mentor may

be released from the program for failure to meet the program requirements. Obtaining a mentor and insuring a continued mentor relationship during the Residential Phase as well as Post-Resident Phase is the responsibility of the cadet and cadet’s parents or guardian. 5. POST RESIDENTIAL PHASE

a. The Post Residential Phase is a 12 month off-campus phase where the focus is on placement of a Cadet. Mentors and parents/guardians provide guidance and support to Graduates while ChalleNGe case managers monitor and document Cadet and Mentor activities. Cadets follow and utilize a Post- Residential Action Plan (“P-RAP”) developed during the Residential Phase to guide them toward their goals and success. Success in the Post Residential Phase is to insure a Cadet is productive a minimum of 30 hours per week; gainfully employed , school full/part time, and maintains contact with the mentor and Academy. Cadets are required to contact mentors at least once a week or four hours per month and contact the Academy at the end of every month. Please note that parents and mentors will be contacted to verify their “placement” and this is a necessary part of the program. 6. ACKNOWLEDGEMENT and CONSENT

I have read the above Program Description and consent to our child/ward’s participation in the National Guard Youth ChalleNGe Program.


I consent and agree to the enrollment of the candidate/cadet into the Alaska Military Youth Academy’s ChalleNGe Program and all the elements of the program. The opportunity to participate in the ChalleNGe Program is accepted entirely at my own risk and at the risk of my child/ward. We accept the risks that are inherent in the activities and programs described in this Notice. 7. TRANSPORTATION CONSENT

I understand and agree that the candidate/cadet will occasionally be transported by aircraft and/or surface motor vehicles while enrolled in the Alaska Military Youth Academy.

I consent and authorize the United States of America, State of Alaska, the Alaska Military Youth Academy and the Alaska National Guard to transport the candidate/cadet as a passenger in or on United States of America, State of Alaska and/or Alaska National Guard aircraft and/or surface motor vehicle during the period that he or she is participating in the Alaska Military Youth Academy’s ChalleNGe Program. This transportation is accepted entirely at my own risk and at the risk of the candidate/cadet. In consideration for the transportation provided, I release and forever discharge the governments of the United States of America and the State of Alaska, and their employees and agents, acting officially and otherwise, from any and all claims, demands, actions, or cause of action, for any injury or illness to the candidate/cadet, or loss of personal property which my occur from any cause during said transportation, as well as ground operations incident thereto. 8. RELEASE AND WAIVER

In consideration for the privilege and opportunity of attending the ChalleNGe Program of the Alaska Military Youth Academy I release the governments of the United States of America and the State of Alaska and all employees and/or agents thereof, acting officially or otherwise, from all claims, demands, actions, or cause of action, due to any injury to, or illness of the candidate/cadet, or loss of personal property which may occur from any cause during the participation of the candidate/cadet in the Academy’s Challenge Program and any and all activities incident thereof.

By signing below you acknowledge that you have read, understand and agree with the contents of the Program and Description Waiver form. Parent/Guardian (1) (Parent signature not required for those age 18) _________________________________ Date: _______________ Signature _________________________________ Printed Name Parent/Guardian (2) (only one parent signature is required unless minor is in joint custody and required by custody agreement) _________________________________ Date: _______________ Signature _________________________________ Printed Name Applicant (future Candidate/Cadet) _________________________________ Date: _______________ Signature _________________________________ Printed Name

AMYA APPLICATION PACKET- Notification of Transportation Responsibility 10 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

NOTIFICATION OF TRANSPORTATION RESPONSIBILITY

Dear Parent or Guardian:

The purpose of this memorandum is to notify you that if your Candidate desires to leave the ChalleNGe Program, or if the parent/guardian desires to have a Candidate leave the ChalleNGe Program, within the first 21 days of the program, it is the parents/guardians responsibility to pay for his/her return home. During the first 21 days of the program the Alaska Military Youth Academy will pay to return Candidates home only when the Academy releases Candidates for cause, either for medical, behavioral, or other reason. Candidates released after day 21 of the program will be returned home at the Academy’s expense.

We welcome your Candidate to the Alaska Military Youth Academy ChalleNGe Program and are excited to have them attend and complete the program. The first three weeks of this program are very intense and challenging for the Candidates and their families. Experience has proven that a Candidate who remains in the program beyond the Pre-ChalleNGe Phase and enters the Residential Phase is much more likely to succeed in completing the program. Unfortunately, there are times when a Candidate, or the Candidates parent/guardian, desire to leave the program within the first 21 days. If your Candidate chooses, or if the parent/guardian desires to have a Candidate leave the ChalleNGe Program within the first 21 days of the program, it is the parent/guardians responsibility to pay for his/her return home.

It is our goal to have all candidates start and successfully complete the Alaska Military Youth Academy program. We look forward to this upcoming class cycle and appreciate your support in encouraging your Candidate to successfully complete the program.

The undersigned acknowledges the financial responsibility to return a Candidate to his/her home, if the Candidate leaves the ChalleNGe Program prior to day 21 of the program and the Candidate leaves based on the Candidate’s or parent/guardian’s desire.

_________________________________ Printed Name (Parent/Guardian or applicant if 18)

_________________________________ ___________________ Signature (Parent/Guardian or applicant if 18) Date

AMYA APPLICATION PACKET- Parent Support Contract 11 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

PARENT SUPPORT CONTRACT

I consent and agree to the enrollment of _________________________ (Applicant’s Name Here) in the Alaska Military Youth Academy ChalleNGe Program and the associated vocational and academic programs. The opportunity to participate in the ChalleNGe Program is by invitation, and is purely voluntary on our behalf.

I am aware that the candidate/cadet will be facing many physical and mental challenges on a daily basis. These challenges are an integral part of the ChalleNGe Program. These challenges are designed to build self-esteem, to create a climate of accomplishment, and to encourage and develop team cohesiveness.

As with all true challenges, there will be times of self-doubt and frustrations to overcome. I understand there may even be periods when the candidate/cadet looks to me as a potential “tool” to enable his or her limited participation or departure from the Academy.

No cadet at the Alaska Military Youth Academy’s ChalleNGe Program will be successful without the support and active participation of that cadet’s parents or guardians. I therefore agree and contract to support the efforts of the ChalleNGe Program by supporting my candidate/cadet in his or her efforts to succeed. I will demonstrate this support by providing praise and encouragement in times of success, and reassurance and motivation during times of frustration. I am committed to the maximum extent possible, to ensure my cadet remains in the ChalleNGe Program until completion of the twenty-two week residential phase and one year Post Residential phase that follows.

In consideration, the Alaska Military Youth Academy agrees to provide me with advice about my cadet’s continued participation in the program, and will also keep me informed about the progress of my cadet in the ChalleNGe Program.

Parent/Guardian (or applicant if 18): *Additional Parent/Guardian:

________________________________ _________________________________ Signature Signature

________________________________ _________________________________ Printed Name Printed Name

___________________ _________________ Date Date

*required if by custody agreement

AMYA APPLICATION PACKET- Model Consent & Release 12 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

MODEL CONSENT &RELEASE

I understand and agree that __________________________ (here in after “the cadet”) may be photographed, videotaped, audio taped, filmed by motion picture equipment, or otherwise have his or her voice and likeness recorded while enrolled in the Alaska Military Youth Academy.

I hereby grant to the Alaska Military Youth Academy and the governments of the United

States of America and the State of Alaska the right to use for promotional, recruiting, training, advertising, news, or any other purpose, the likeness and voice of the cadet, as recorded at the Alaska Military Youth Academy, for an unlimited period of time beginning on the date this document is signed.

I further understand and agree that the consideration for the release for use of any still

photographs, videotape recordings, motion picture images, audio recordings, or any other representations of, or actual renditions of the cadet’s likeness or voice captured or produced in conjunction with any and all activities, is cadet’s opportunity to attend, and actual attendance at the Alaska Military Youth Academy.

(Parent/Guardian signature not required for applicants 18 years of age) Parent/Guardian Additional Parent/Guardian _______________________________ _________________________________ Signature Signature _______________________________ _________________________________ Printed Name Printed Name I have read this document, understand its contents, and agree with and approve all of the terms and conditions set thereon. _______________________________ ___________ Applicant Signature Date _______________________________ Applicant Printed Name

AMYA APPLICATION PACKET- Release of Information 13 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

RELEASE OF INFORMATION AMYA Post-Residential

Secure Fax: 907-384-6023 E-mail: [email protected]

I, _________________________________________, cadet/graduate, of the Alaska Military Youth Academy (Print First Middle Last Name)

Academy (AMYA), hereby give permission to request information regarding employment status, school status (Ex: Jr.

College, Vo-Tech, University, Job Corps, GED program), military status (to include copies of orders), volunteer status,

placement in treatment facility, detention or correction facility to be released to any staff member of AMYA as agreed

upon my entry of the program in order to fulfill my Post-Residential requirements that I must remain in active placement

for 12-months following completion of the program and that I must provide validation of that placement. The

information obtained will not be released to any other persons or organizations and is used solely to verify placement

status.

The signing of this agreement is my consent to allow information to be released regarding my status/placement.

This release expires at the end of the cadet/graduates post-residential phase which is eighteen (months) following the

start of the Cycle.

Cycle Start Date: ________________________

Cadet/Graduate’s Full Name (Print): _______________________________________

Cadet/Graduate’s Signature: ____________________________________________

Graduate’s Social Security Number: __________- _________-____________

Graduate’s Date of Birth: _____________________________________

(If under 18) Cadet/Graduate’s Parent/Guardian Name (print): _______________________________________

Cadet/Graduate’s Parents/Guardian Signature: ____________________________________________

AMYA APPLICATION PACKET- Free from Adult Level Felony 14 REVISED 10.8.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

Free from Adult Level Felony Declaration This form is for only youth who are/have been involved in the criminal justice system.

I, __________________________, juvenile probation officer or authorized Division of Juvenile DJJ Staff Name

Justice Representative for AMYA applicant, _______________________, born ___/___/_____, Applicant Name MM DD YYYY

declare that he/she is not on probation/parole nor under indictment, charged, or convicted of a

Felony Offense in Adult Court. ____________________________ _____________________ _______________ DJJ Staff Signature Title Date

Youth at AMYA cannot have pending case issues/court requirements during 22 week residential phase of the program.

In addition, AMYA requires copies of Probation Conditions, Disposition/Adjudication Order, HIA Agreement or Informal Probation Agreement as well as a list of all charges and outcomes. This declaration and additional information is required for the applicant’s AMYA admission. It is also highly recommended that the youth/family sign DJJ specific release of information to allow contact and follow-up while at AMYA and in the 12 months following their completion of our residential phase.

AMYA APPLICATION PACKET- Internet User Student Agreement 15 REVISED 5.15.13

Internet User Student Agreement Dear Parent/Guardian, We allow cadets in the Alaska Military Youth Academy access to the campus computer network for filtered internet access only. To obtain internet access, all cadets must read and sign the following agreement. Access to the Internet enables cadets to explore thousands of libraries and databases, and other helpful resources. However, be advised that some material accessible via the Internet may contain items that are illegal, inaccurate, degrading and offensive. Our intent is to make Internet access available to further educational goals and objectives. Therefore we restrict websites that are not a part of their research or academic assignments. We are connected to a fiber optics system with firewall software installed and Academy staff will monitor and supervise all Internet and computer activities at all times. Academy Internet Privileges and Responsibilities Cadets are responsible for good behavior on Academy computer networks just as they are in a classroom. General Academy rules for behavior and communications apply. The network is provided for cadets to conduct research. Access to network services is given to cadets who agree to act in a considerate and responsible manner. Access to the Academy’s network is a privilege, not a right; access entails responsibility. For security and management purposes, access to the Internet will be limited to Computer Lab 1, Bldg 60704, for academic instruction and the Job Center, under the supervision of the Cadet Services staff. Cadets will not be allowed Internet access at their Job Skills worksite. Individual users of the Academy computer network are responsible for their behavior and communications over those networks. It is expected that users will comply with the Academy standards and will honor the agreements they have signed. The following are not permitted: • Visiting websites that contain the following subject matter: drugs, pornography, violence, gambling,

games, chat rooms, music downloads, video downloads, shopping or any other website not directly related to academic studies or goal setting.

• Access to email accounts of any type • Sending or displaying offensive messages or pictures • Harassing, insulting, or attacking others • Violating copyright laws • Using another’s password • Trespassing in another’s folders, work or files

AMYA APPLICATION PACKET- Internet User Student Agreement 16 REVISED 5.15.13

The following are not permitted (cont): • Employing the network for commercial purposes • Deliberate damage to hardware or software • Hacking of any kind. It is a felony to hack a government network. • Use of Academy computers for illegal activities Violations may result in a loss of access as well as other disciplinary or legal action. The Alaska Military Youth Academy is not liable for any harm or injury that a user may suffer as a consequence of any inaccurate information the user may obtain through the Internet. By entering into this User Agreement, the user agrees to be bound by this release of liability and waives any and all rights to assert claims, which may arise due to use of these electronic services. As a user of the Alaska Military Youth Academy computer network, I hereby agree to comply with the rules stated on the reverse side of this form regarding communications over the network, while honoring all relevant laws and restrictions. Please print the information below. STUDENT (Applicant) Student Name: _______________________________________ Student Signature: ____________________________________ Date: __________________ As a parent or legal guardian of the cadet signing above, I grant permission for my cadet to access networked computer services on the Internet. I recognize every effort is being made for the Alaska Military Youth Academy to restrict access to all controversial materials. I hereby give permission for my child to access the Internet and certify that the information contained on this form is correct. This permission shall be in effect as long as this cadet is enrolled in the Alaska Military Youth Academy. I may at any time revoke this permission by notifying the Academy in writing. (Parent signature not required for youth 18 or over) PARENT OR GUARDIAN Parent/Guardian Name: _______________________________________ Parent/Guardian Signature: ____________________________________ Date: ________________

AMYA APPLICATION PACKET- Transcript Request-REMOVE FROM PACKET 17 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

REQUEST FOR TRANSCRIPTS

(REMOVE FROM APPLICATION AND PROVIDE COPY TO YOUR SCHOOL) TO: _______________________________

_______________________________

_______________________________

My child/ward, ________________________________, date of birth: ____/____/_______,

SSN (or student ID number) _____________________________, is applying for admission to the Alaska

Military Youth Academy’s next cycle scheduled to begin ___________________.

In order for Academy staff to be able to place him/her at the proper academic level, the Academy needs

copies of all his/her school medical, academic and counseling records, including but not limited to any

Individual Education Plan (IEP) used during his/her school grades 7-12.

Please send the requested copies to: Alaska Military Youth Academy Registrar PO Box 5727 JBER, AK 99505-0727 Fax: 907-384-6196

Thank You:

_________________________________ ______________ Signature of Parent/Legal Guardian Date

*Note to Parent/Guardian: A copy of this letter is to be delivered or sent by you to the last school attended by the applicant. Failure to provide full records as indicated above may result in denial of admission. Records MUST arrive by the start of the class.

.

AMYA APPLICATION PACKET- Transcript Request 18 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

REQUEST FOR TRANSCRIPTS

(PROVIDE THIS AT TIME OF INTERVIEW) TO: _______________________________

_______________________________

_______________________________

My child/ward, ________________________________, date of birth: ____/____/_______,

SSN (or student ID number) _____________________________, is applying for admission to the Alaska Military

Youth Academy’s next cycle scheduled to begin ___________________.

In order for Academy staff to be able to place him/her at the proper academic level, the Academy needs copies

of all his/her school medical, academic and counseling records, including but not limited to any Individual

Education Plan (IEP) used during his/her school grades 7-12.

Please send the requested copies to: Alaska Military Youth Academy Registrar PO Box 5727 JBER, AK 99505-0727 Fax: 907-384-6196

Thank You:

_________________________________ ______________ Signature of Parent/Legal Guardian Date

.

AMYA APPLICATION PACKET- Power of Attorney 19 REVISED 10.8.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

POWER OF ATTORNEY

I, _________________________, herby grant to the Alaska Military Youth Academy (a division of the Alaska

Department of Military &Veteran’s Affairs) any powers that I may have regarding care, custody, and control of the person of ___________________________, (hereinafter “the minor”) except to marriage or adoption. This power is granted pursuant to Alaska Statute 13.26.020.

Specifically included within this Power of Attorney is the grant of authority to the Alaska Military Youth Academy to consent to medical and dental procedures on behalf of the minor, in the situation where neither I nor any other parent or legal guardian of the minor can be contacted within a reasonable time, or the situation where neither I nor any other parent or legal guardian is able make medical and dental decisions or consent to medical and dental procedures on behalf of the minor.

Also specifically included within this Power of Attorney is the grant of authority to the Alaska Military Youth Academy the power to request, review, and receive any information, verbal or written, regarding the minor’s physical or mental health, including, but not limited to, medical, dental, hospital and school records, and to execute on my behalf any releases or other documents that may be required in order to obtain this information.

The power given herein is granted to insure the safety and well being of the minor and shall be effective for the period of time that the minor is enrolled in the residential phase of the Alaska Military Youth Academy’s ChalleNGe Program. Should the minor be dis-enrolled from the Military Youth Academy for any reason, this power of attorney shall terminate immediately.

The Power granted herein shall be exercised only by the Director, Deputy Director, Commandant of Cadets, or Principal of the Alaska Military Youth Academy.

In no event shall this power of attorney extend for a period greater that 12 months from the date that I sign this document.

Nothing herein shall mean that I relinquish any legal right to custody of the minor but gives Attorney in Fact authority to act on my behalf. Signed and sworn to this ______ day of _______________ in the year _________________ by: Parent/Guardian (1) or applicant if age of legal consent)

_________________________ Printed Name

________________________________________________________________________________

Address On this date, before me, a Notary Public, personally appeared:

*_____________________________ Parent/Guardian Signature *in presence of Notary (or applicant if age of legal consent)

AMYA APPLICATION PACKET-Power of Attorney 20 REVISED 10.8.13

In the State of ___________, ___________Judicial District Known to me or satisfactorily proven to be the person(s) whose name is subscribed to this instrument and

acknowledge that he/she/they executed the same. If this/these person(s)’ name (s) is/are subscribed in a representative capacity, it is for the principle named in the capacity indicated.

________________________ Date _________________________ Notary Signature My commission expires: _____________________________

________________________________________________________________________________________________ Additional Parent/guardian-required only in shared custody when agreement requires. Signed and sworn to this ______ day of _______________ in the year _________________ by: Parent/Guardian (2)

_________________________ Printed Name

________________________________________________________________________________


_______________________________ Parent/Guardian Signature in presence of notary In the State of ___________, ___________Judicial District Known to me or satisfactorily proven to be the person(s) whose name is subscribed to this instrument

and acknowledge that he/she/they executed the same. If this/these person(s)’ name (s) is/are subscribed in a representative capacity, it is for the principle named in the capacity indicated.


.

AMYA APPLICATION PACKET- Medical Power of Attorney 21 REVISED 10.8.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

MEDICAL POWER OF ATTORNEY

I, _______________________________________ ,(name of parent/guardian or applicant if age of legal consent), hereby grant to the Alaska Military Youth Academy (AMYA) (a division of the Alaska Department of Military & Veterans Affairs (DMVA)) the authority to administer over-the-counter medications to my child or ward (or applicant name if age of legal consent), ______________________________________, while he or she is in attendance at AMYA. In administering medications under this power of attorney, AMYA shall act as reasonably prudent parents would in caring for their child.

The authority granted herein shall be exercised only by the Director, Deputy Director, Commandant of Cadets, Principal or Team Leaders of the AMYA. The authority granted herein may also be exercised by nursing staff hired or contracted by AMYA.

I do not want the following over the counter medications to be given to my child or ward, and AMYA is not authorized to give the following over-the-counter medications to my child:

_________________________________________________________________________

_________________________________________________________________________

In signing this power of attorney I certify that I am not aware of any allergies to any over- the-counter medications that my child or ward may have, other than those listed above, or previously disclosed to AMYA on a form provided by AMYA.

In no event shall this power of attorney extend for a period greater that 12 months from the date that I sign this document. Signed and sworn to this ______ day of _______________ in the year _________________ by: Parent/Guardian (1) or applicant if age of legal consent)

_________________________ Printed Name

________________________________________________________________________________


*_____________________________ Parent/Guardian Signature *in presence of Notary (or applicant if age of legal consent)

AMYA APPLICATION PACKET-Medical Power of Attorney 22 REVISED 10.8.13

In the State of ___________, ___________Judicial District Known to me or satisfactorily proven to be the person(s) whose name is subscribed to this instrument



________________________________________________________________________________________________ Additional Parent/guardian-required only in shared custody when agreement requires. Signed and sworn to this ______ day of _______________ in the year _________________ by: Parent/Guardian (2)

_________________________ Printed Name

________________________________________________________________________________


_______________________________ Parent/Guardian Signature in presence of notary In the State of ___________, ___________Judicial District Known to me or satisfactorily proven to be the person(s) whose name is subscribed to this instrument



.

AMYA MEDICAL PACKET-CHECKLIST 1 REVISED 5.15.13

ALASKA MILITARY YOUTH ACADEMY Anchorage Admission Office 800 East Dimond Blvd., Suite 3-229 - Anchorage, AK 99505

Phone: 907.375.5554 or 907-375-5556 Fax: 907.375.5557 Satellite Admission Office Mail: PO Box 70628 Fairbanks, AK 99707 Physical: 202 Wien Ave. Fairbanks

Phone: 907.374.7960 Fax: 907.379.7969

Medical Packet Checklist Please bring this packet with you to your interview. (Bolded items required at time of interview)

□ Medical Care Authorization □ Request for Immunization Records (from school) or provide copy of immunization record □ Medical History □ Physical Form (requires medical appointment, take this form with you. You may also use the physical form

preferred by your clinic or health care provider*)*If you have had a physical within the past 6 months, you may submit this in lieu of our physical form. Please contact admission staff if you are unable to obtain a physical due to location or lack of funds.

□ PPD Screen [Tb screen] (If positive: all follow up must be done prior to entry including chest x-ray, start of medication and clearance from the Public Health Department)

□ Consent for Release of Information □ Notice of Program Participant Status During the Residential Phase □ Dental Health Verification Form- highly recommended, but not required □ Read Special Requirements for Military Dependents and Cadet Insurance Information

The medical staff welcomes your son or daughter to the Academy. One of the goals of the Alaska Military Youth Academy is to care for the physical and mental health of your cadet while in residence. This job begins prior to admission by ensuring all cadets are ready and prepared for their stay with us. The clinic is staffed seven days a week with Registered Nurses beyond regular business hours. Cadets receive routine medical care from a Family Nurse Practitioner. If you have any questions about completing the below tasks, please call the Nursing Staff for assistance at: 907-384-6115

• What to take to the physical: History Form, Physical Form and Required immunization Form • If outside appointments are necessary during the residential period, the Nursing Staff will arrange times and

transportation. If the parents live locally, the Nursing Staff may ask the parent to transport the cadet. No appointments should be made by parents for your cadet while in attendance, without making prior arrangements with the Nursing Staff. The nursing staff can assist parents in minimizing the effect outside appointments have on planned AMYA activities including classes, testing, and other scheduled training.

• A dental exam is medically advised; all necessary work should be done prior to admission. Only urgent dental needs will be met during residence; elective or non-urgent procedures will be postponed until after residency. Tooth pain can be severe and may prevent your child from full participation. Give your child the best chance to succeed by preventing absences from AMYA and activities for dental work. If you are not able to provide a dental exam due to location or financial reasons, please call the Nursing Staff to discuss your situation.

• Do not bring contact lenses. Two pairs of glasses are required.

• Medications are administered by the registered nurse or an authorized person for your cadet. If possible, medication prescriptions need to be supplied for the 6 month duration. Applicants are required to have at least a 30 day supply of needed medications and two months of refills (prescriptions). Medications to bring include any that your cadet is currently prescribed including asthma inhalers and EpiPens.

• Please use the following Checklist above to ensure your Medical packet is Complete; then fax copy of all medical records to: 907-384-6045. Originals should be submitted with admission application.

AMYA MEDICAL PACKET- MEDICAL CARE AUTHORIZATION 2 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

Medical Care Authorization

I/We understand that my/our child/ward (or self if age of legal consent) __________________________ (applicant’s name)

will be provided limited medical care during his/her participation at the Alaska Military Youth Academy. I/We therefore consent, in advance, to allow whatever emergency medical treatment is considered necessary by

attending medical staff in the event my/our child/ward suffers illness or injury during his/her participation at the Academy. I/We understand that every reasonable effort will be made to notify me/us of illness or injury to my/our child/ward. I/We understand and agree that any necessary medical treatment will not depend upon such notifications.

Please check one of the following statements:

_________I/we do not currently possess medical treatment rights or medical insurance to cover costs incurred for

medical treatment for my/our child/ward. If you do not have insurance proceed to the bottom of next page.

_________I/we currently possess medical rights and /or insurance under which my/our child/ward is covered. (Examples

of rights/ insurance include, but are not limited to active duty military dependent, Medicaid, Indian Health Service

access, private or group health insurance plans.) Please complete the following;

My/our Health right/insurance provider/agency’s name:____________________________.

Persons name policy is in:_________________________________; Group #____________, Policy

#___________________________, Member #___________________,

BIA #________, Medicaid #__________________ Expiration date of the policy:_________

Co-pay amount _____ Coverage type (check all that applies):

Full Medical ____ Dental ____ Vision ____ Prescriptions ____

Insurance Co. address: __________________________________________________________

__________________________________________________________

__________________________________________________________

Insurance Co. Ph #: ____________________ Date of Birth of policy holder________________

SSN # of policy holder:___________________ Employer:_____________________________

Attach copies of insurance forms and CARDs, Military Identification CARDS, and Tricare cards (front and back), Medicaid sticker, and Denali Kid Care card.

AMYA MEDICAL PACKET- MEDICAL CARE AUTHORIZATION 3 REVISED 5.15.13

Complete if you have secondary insurance;

My/our Secondary health rights/insurance provider/agency’s name is: _____________________.

Persons name policy is in: _________________________________.

Group #____________ Policy #_________________ Member #______________

BIA #________ Medicaid #__________________ Expiration date of the policy:_________

Co-pay amount ____ Coverage type (check all that apply): Full Medical__ Dental __Vision__ Prescriptions___

Insurance Co. address: __________________________________________________________

__________________________________________________________

Insurance Co. Phone #: ___________________________

Date of Birth of policy holder:___________________________

SSN # of policy holder:_________________ Employer _______________________________

Attach copies of insurance forms and CARDs, Military Identification CARDS, and Tricare cards (front and back), Medicaid sticker, and Denali Kid Care card.

I/We understand that while my/our child/ward is attending the Alaska Military Youth Academy he/she will be required

to be enrolled in a public assistance program (Medicaid or Denali Kid Care) in his/her name.

In the event that the status indicated above changes, I/We agree to immediately notify the Alaska Military Youth

Academy in writing.

Signed this ________________day of ____________in the year ___________by:

Parent/ Guardian Signature ______________________ Printed Name _____________________

(or self if legal age of consent)

IF APPLICANT QUALIFIES FOR SERVICES THROUGH THE ALASKA NATIVE MEDICAL CENTER, PLEASE CONTACT 907-563-

2662 AND ASK TO SPEAK WITH REGISTRATION IN ORDER TO ENSURE APPLICANT WILL HAVE ACCESS TO THESE

SERVICES WHILE IN THE ANCHORAGE AREA.

AMYA MEDICAL PACKET- REQUEST FOR IMMUNIZATIONS 4 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

Request for Immunization Records (provide this copy to your school)

TO: ____________________________

____________________________

____________________________ (Name & Address of School)

My child/ ward, _________________________________, date of birth: ______/______/______

SSN (or student ID)_____________________________, is scheduled to begin enrollment at the Alaska Military

Youth Academy.

In order for the medical staff to provide a safe environment and ensure all students are up to date on required vaccinations, the Academy requests a copy of the immunization records be sent to the Medical Section staff. Fax copies are acceptable (private fax): 907-384-6045

Alaska Military Youth Academy Medical Section PO Box 5727 JBER, AK 99505-0727 For any questions, please contact the medical section staff at 907-384-6115 Thank you,

______________________________ ______________________________ Parent Signature Date Signed Note to parent: Immunizations required for school entry: Hepatitis A, Hepatitis B, Polio, MMR (measles, mumps, rubella), Tetanus/ Diphtheria (within past 10 years), and PPD testing [Tb testing] (within past 6 months). It is highly recommended to get the Meningococcal and Varicella vaccines due to the communal living (open bay barracks). Please see the immunization information sheet.

AMYA MEDICAL PACKET- IMMUNIZATION INFORMATION 5 REVISED 5.15.13

Required Immunizations

Fax Records to Medical Section at 907-384-6045

• HEPATITIS A • HEPATITIS B • POLIO • MEASLES, MUMPS, RUBELLA (MMR) • DIPTHERIA/ TETANUS. • PPD screen [Tb screen] within 6 months (If positive, all follow up must be complete prior to

admission) HIGHLY RECOMMENDED

• MENINGOCOCCAL • VARICELLA (CHICKENPOX) • INFLUENZA

IMMUNIZATION CLINICS-WHERE YOU CAN GET FREE IMMUNIZATIONS

Alaska Regional Hospital- Medical Plaza 1200 Airport Hts., Plaza Bldg., Suite 250 276-1131, Third Saturday of each month, 9:00 AM-1:00 PM For ages 18 and under, walk in only

Alaska Native Medical Center 4320 Diplomacy Drive 729-1000 Monday-Friday 9:00 AM-4:30 PM Eligible Clients and by appointment only

Anchorage Neighborhood Health Center 1217 E. 10th Street 257-4600, Monday through Thursday 8:00 AM to 8:00 PM Friday 8:00 AM-5:00 PM By Appointment Only

Elmendorf Air Force Base Hospital 3rd Medical Group 580-5812 Monday-Friday 7:15-4:15 pm Closed every 3rd Thurs. 11:30 am, and No TB test every Thursday Eligible military dependents and walk in only

Municipality of Anchorage Dept. of Health and Human Services 825 “L” Street 343-4799 Monday 8:00 AM-5:30 PM Tuesday-Thursday 1:00 PM-5:30 PM Friday 8:00 AM-4:30 PM For ages 18 and under, walk in only

Providence Alaska Medical Center 3200 Providence Dr., Tower B 3rd Floor Suite 314 212-4824 First Saturday each month 10:00 am- 1:00 pm For ages 18 and under, walk in only

Always take your shot record with you to every visit!

Outside Anchorage Area Immunization Helpline: 888-430-4321

or http://www.epi.alaska.gov/id/immune.stm

http://www.epi.alaska.gov/id/immune.stm

AMYA MEDICAL PACKET- MEDICAL HISTORY 6 REVISED 5.15.13

ALASKA MILITARY YOUTH ACADEMY MEDICAL HISTORY

APPLICANT NAME_____________________________AGE_____SEX____ (CHECK EACH ITEM) DO YOU HAVE NOW OR HAVE YOU EVER HAD ANY OF THE FOLLOWING

FOR ANY “YES” ANSWER, GIVE AGE, DATES OF OCCURRENCE AND EXPLANATION BELOW AND ON BACK OF FORM Yes- Explain (year, details) No Explain problems of: Yes-Explain (year, details) No 8. NEUROLOGICAL PROBLEMS

Drugs Head injury Foods/ Seasonal Allergies Dizziness or Fainting spells 2. HEAD AND NECK PROBLEMS Periods of unconsciousness Severe/ recurring headaches Epilepsy, Fits or Seizures Wear glasses or contact lens Other neurological problems Loss of vision in one or both eyes 9. MUSCULAR / SKELETAL PROBLEMS Ear problems Inability to perform certain Motions or

Positions Wear a hearing aid Bone, Joint, or Other deformity Sinus or Nose problems Loss of a Finger or Toe Chronic colds or Sore throat Arthritis Tooth/ Gum pain Wear a back support Other throat problems Ruptured disk Other head or neck problems Pain of joints 3. RESPIRATORY PROBLEMS Wear Braces, Prosthesis, or Supports Had Tuberculosis Painful or “Trick” shoulder Coughed up blood Painful or “Trick” Elbow Lived with anyone who had TB Wrist or Hand problems Pneumonia “Trick” or Painful hip Shortness of breath Painful or “Trick” or Locked knee Asthma Cramps in legs Other lung problems Weak or Painful Ankles 4. HEART PROBLEMS Flat feet Pain or Pressure in chest Broken bones Palpitations or Pounding heart Other muscular /skeletal problems Other heart problems 10. OTHER MEDICAL PROBLEMS Family history of Heart Disease Chicken Pox (Varicella) 5. DIGESTIVE PROBLEMS Jaundice or Hepatitis Frequent indigestion Bled excessively after injury Ulcers Hemophilia Hemorrhoids Foot trouble Constipation/ Diarrhea Skin diseases Other digestive problems Rupture or Hernia 6. URINARY TRACT PROBLEMS Excessive fatigue Bedwetting after age 12 Frequent trouble sleeping Kidney Stones Diabetes Pain on urination Thyroid Disorder Other urinary tract problems Ever have surgery recommended? 7. Mental health Had any operation Depression Treated for a female disorder Anxiety Are you pregnant? Attach current test

results Other Excessive weight Gain or Loss Take medication (Please provide 6 refills)

FOR SCHOOL ATTENDENCE STATE LAW REQUIRES HEPATITIS A, HEPATITIS B, POLIO, MEASLES, MUMPS, RUBELLA (MMR), DIPTHERIA/ TETANUS IMMUNIZATIONS. IT IS HIGHLY RECOMMENDED TO GET MENINGOCOCCAL and VARICELLA IMMUNIZATION To the best of my knowledge, the information I have provided on this page is complete and true.

______________________-________ _______________________-_______ Applicant’s Signature Date Parent Signature Date

AMYA MEDICAL PACKET-PHYSICAL EXAM 7 REVISED 5.15.13

ALASKA MILITARY YOUTH ACADEMY PHYSICAL EXAM FORM

Name: ________________________ DOB: ___/___/___ Sex: ____ Allergies:_____________________

Ht: ______ Wt: _____lbs. BMI: _____Temp: ____F Pulse: ____ Resp: _____BP: ____/____

STI exposure: Y/N Tanner Scale: ________ Substance Use: __________________________

Females Only: LMP:___/____/____ Menarche:_____ yo Dysmenorrhea Y/ N

Vision Test R: ___/____ L ___/____ B____/____ (Cadet must have two pairs of glasses)

Current Medications:___________________________________________________________________ (please ensure student will have refills for 5 ½ month residency, IF CONTROLLED MEDICATION contact 907.384.6115) System Normal Initial

Normal Abnormal/ Findings

General Screen Marfan syndrome MS FROM all joints. No Pain, Deformity. (If pain or prior

injury, consider order for brace).

Eyes WNL Ears WNL. Nose WNL. Mouth WNL: (Dental exam medically advised) Sinus WNL Lymph WNL CV WNL (For abnormal: Do cardiac workup prior to

clearance)

Lungs WNL (For EIA: Please ensure inhaler is RX) Abdomen WNL Derm WNL No Scabies or Pediculosis Genitals (male only)WNL Neuro WNL **TB test (Type) ____________Date___________________ Results __________________ (must be within 6 months) Treatment for abnormal:____________________________________________________ Follow up (specify timeframe):____________________________________________________________ I have examined the above individual and: [ ] Declare the individual free of communicable disease, physically and emotionally ready for entrance into the Alaska Military Youth Academy Challenge Program without any restriction to activity. [ ] Recommend the individual be followed by a physician for medical reasons (specify below). [ ] Restrict physical activity to exclude the following activities: __________________________________________________________________________________________

__________________________________ _____________________ Signature and Title of Examiner Date __________________________________ ____________________________________ Printed Name and Title Name of Clinic __________________________________ (____)_______-__________ Address Phone

AMYA MEDICAL PACKET- MEDICAL CONSENT TO RELEASE INFORMATION 8 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

MEDICAL CONSENT FOR RELEASE OF INFORMATION (During Residence)

Purpose of this Form: This form is used by AMYA medical staff, in the event information and/or health records are required concerning an AMYA cadet. This consent form is intended to allow AMYA medical staff, when they determine it is reasonably necessary, to either request medical records on a cadet that are maintained by other care providers, or to release medical records on a cadet to other governmental or insurance organizations. This consent form will only used by AMYA medical staff for care the cadet receives during the residential phase of the program.

Here are some examples of how this consent form may be used by AMYA staff: AMYA medical staff may request records from your cadet’s primary care provider or specialist to learn about medications the cadet is taking, or restrictions on that cadet’s permitted activity. Other instances this form may be used might include cases where your cadet needs care from an outside provider while in residence at AMYA. For example, if your cadet should have an accident and be transferred to an emergency room, the AMYA nursing staff may request the records of that ER visit, so that AMYA staff have the needed records that show how your cadet was treated.

AMYA staff may also use this consent form to facilitate or administer payment associated with a cadet’s medical care.

Your written consent below gives AMYA the power to request medical records on the listed cadet on your behalf, in line with all applicable federal and state laws.

Please fill in Parent/Guardian, name of child/ward, date, sign, and have signature witnessed.

I, _________________________________________ authorize the release of information Parent/Guardian/Self(if 18) concerning my child/ward or myself, _____________________________. Child/Ward To whom it may concern: I understand and agree that the medical information on the above named person is to be released by or to one or more of the following: 1) any health care provider, to whom AMYA staff has referred a cadet for care; 2) any health care provider from whom the cadet may be receiving care, under arrangements by the cadet’s parent/ guardian; and/or 3) any agency, insurer, or other agency that reasonably requests the medical information for financial reimbursement purposes. The medical information covered by this consent form may include any or all of the following:

Medical Treatments, Psychological and Drug/Alcohol Abuse Counseling notes, Progress notes, Laboratory or radiology test results, Diagnoses and treatments.

AMYA MEDICAL PACKET- MEDICAL CONSENT TO RELEASE INFORMATION 9 REVISED 5.15.13

The information that is obtained by the above named individuals or organizations will not be released to any other persons or organizations, except for the purposes specified above.

I understand that I may revoke this authorization at any time with written notification to AMYA, except for action AMYA staff may already have taken in compliance with this authorization. In the absence of such written revocation by me, this consent will automatically expire in two years. I understand that I have a right to receive a copy of this request.

Signed this ____________ day of _______________ in the year_________ by:

______________________________ _____________________________ Parent/Guardian Print Parent/Guardian Signature (Minors only) ______________________________ _____________________________ Applicant Signature Witness

AMYA MEDICAL PACKET- DENTAL HEALTH VERIFICATION 10 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

DENTAL HEALTH VERIFICATION (RECOMMENDED, BUT NOT REQUIRED) It is medically advised to get a dental exam prior to admission to ensure your cadet is ready and able to participate. Only scheduled orthodontic and urgent dental issues are scheduled during your child’s attendance at the Academy. Routine work will be deferred until the post-residency phase. For any questions or help finding a dentist, please call the nursing staff at 907-384-6115. _________________________ has had a current dental examination on ___ /____/_____ Applicants Name M / D / Yr. The Dental examination has indicated the need for intervention or completion of: Fillings or extractions necessary immediately _____________________________________________________ Previous extractions (including Wisdom Teeth) and date completed __________________________________________________________________________________________ Dental conditions: in need of immediate or urgent attention in the following six (6) months. __________________________________________________________________________________________ Other dental work: root canal, crown, prophylaxis, or hygiene: and date of suggested completion. ____________________________________________________________________________________________________________________________________________________________________________________ List any removable prosthetics or retainers_______________________________________ Does this young person require a night guard or any special mouth care on a daily basis?__________________ __________________________________________________________________________________________ Does this young person have a TMJ problem?_____________________________________ This cadet ___WILL / ____WILL NOT be able to complete a six month training program without further dental intervention. ________________________ _____________________ Applicants Signature Parent/Guardians Signature _____________________ ____________________ Dentist’s Printed Name Phone/Address ____________________ _____________________________ ________________ ____________________ Dentist’s Signature Date ____________________

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AMYA MEDICAL PACKET- Notice of Program Participant Status During the Residential Phase 11 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

MEMORANDUM

TO: Parents/Guardians of Challenge Program Applicants SUBJECT: Notice of Program Participant Status During the Residential Phase 1. Please be advised that Participants receiving training during the Residential Phase of the Program are neither Federal employees nor members of the National Guard; however, the Federal Employees Compensation Act (FECA) authorizes them FECA coverage by recognizing them as Federal employees (GS-2) while in attendance.

a. The participant shall be considered Federal employees under Subchapter I of Chapter 81 of Title 5, U.S. Code, for the purpose of compensation for work injuries; and for the purpose of Sections 1346(b) and Chapter 171 of Title 28, U.S. Code, and any other provision of law relating to the liability of the United States for tortious conduct of employees of the United States.

b. If a Participant is injured at an assigned location of training or other activity authorized in accordance with the Program operation, they will be processed through FECA. Participants shall not be considered to be in the performance of duty while traveling to or from the location or is on pass from that training or other activity.

c. In computing compensation benefits for disability or death, the monthly pay of a participant shall be deemed that received under the entrance salary for a grade GS-2 Federal employee.

d. The entitlement of a person to receive compensation for a disability shall begin on the day following the date that the person's participation in the Program is terminated. 2. The FECA claims submission and coordination process is conducted within the State through the AMYA HQ Support Services Section. The Support Services staff will process actions through the SOA FECA Point of Contact (POC). I/We acknowledge receipt of this information and will seek clarification from the appropriate AMYA staff if I/We have additional questions. _____________________________ ______________________________ Parent/Guardian Name (Signature) Applicant Name (Signature) ____________________________ ______________________________ Parent/Guardian Name (Print) Applicant Name (Print)

AMYA MEDICAL PACKET- Medical Letter-Student Insurance 12 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

To: Parent/Guardian

From: AMYA Medical Section

Subject: Student Insurance Information

This letter is intended to clarify the insurance requirements for students at the Alaska Military Youth Academy (AMYA). To ensure that we are able to make available timely medical care to your student while at AMYA, please provide us with the most current and complete insurance information. Please make copies of the front and back of all insurance cards (including DKC) and military identification cards. Attach copies to the Medical Care Authorization form. While your student is attending AMYA, they will be required to be enrolled in a public assistance program, (Medicaid or Denali Kid Care) in their name. When your cadet is enrolled in Denali Kid Care, their coverage starts with the enrollment date issued from Denali Kid Care, and ends one year after that enrollment date. If eligible, the family should register prior to admission into the Academy. If not eligible as a family, the cadet will be registered for Denali Kid Care by the Academy. It is the parents/ guardian responsibility to notify DKC of any changes to the information, including the change of address back to home after graduation and changes to the cadet’s income back to the family income. Your primary and secondary insurance (if applicable) plans will be submitted for covered medical expenses. We must know immediately if there are any changes made to your primary or secondary insurance plans during the 20 week residential phase of the program. If you don’t have insurance, Denali Kid Care will be the primary coverage for your student. For any reason if Denali Kid Care does not pay for a medical appointment or procedure to include Emergency Room visits, or any prescribed medications, then the parent/guardian is responsible for all medical expenses incurred. In the event that AMYA escorts your student to a doctor’s appointment, AMYA will provide your students home mailing address and insurance information as reported by the parent/guardian on the AMYA application form. It is ultimately the parent/guardian’s responsibility to see that all medical expenses are paid. For any medical questions or concerns please call the medical clinic at 907- 384-6115.

AMYA MEDICAL PACKET- Medical Letter-Military Dependents 13 REVISED 5.15.13



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

To: Parent/Guardian From: AMYA Medical Section Subject: Requirements for Military Dependents The following are requirements that must be met by military dependents prior to admission to the academy. The requirements set out below will help permit the cadet to receive medical care during his or her time in residence at AMYA.

1. All military dependent AMYA cadets must have in their possession a valid military identification (I.D.) card that will not expire during the residential period of the program. Without a current military I.D. card, Elmendorf Medical Center will not see the dependent candidate/cadet.

2. The AMYA medical section also needs a front and back copy of the sponsor’s current TRICARE Prime card and proof of current dental coverage. All military dependent AMYA cadets must be enrolled in TRICARE Prime at Elmendorf, in order to be receive medical care. Sponsors of the military dependent may enroll him or her into the TRICARE Prime portability system at the 673rd Medical Group/ Hospital by visiting the TRICARE website or by visiting the nearest TRICARE Service Center. Please notify the AMYA medical staff if you are using TRICARE Standard Healthcare options. The sponsor has the responsibility for ensuring that the dependent cadet can be seen by providers in the TRICARE system, for all necessary appointments during his/her stay, including but not limited to any necessary emergency services.

3. Please update your third party liability insurance with the Resource Management office at the 673rd Medical Group.

4. Please complete the Authorization to Disclose form found at: http://www.triwest.com/en/beneficiary/find-a-form/. This allows AMYA to call to schedule appointments for your dependent cadet, and/or to request health information.

5. All military dependent candidates must stop by the TRICARE table at the AMYA in-processing locations in Fairbanks or Anchorage, in order to ensure all necessary paperwork is complete.

6. If you have questions concerning these requirements, please call the AMYA medical section at (907) 384-6115 or contact TriWest at:

TriWest Healthcare Alliance Beneficiary Services and Educational Representative

Alaska Market Office: 907-273-8715 Fax: 866-302-5857

Email: [email protected]


AMYA Mentor Application- Welcome and Checklist 1 REVISED 1.13.14



P.O. Box 5727 JBER, AK 99505-0727

Main: 907.428.6003 Fax: 907.384.6007

PLEASE PROVIDE THIS APPLICATION TO YOUR POTENTIAL MENTOR Dear Mentor Applicant,

Thank you for your interest in becoming a Mentor for a Cadet in the Alaska Military Youth Academy. Spending time with a young adult, as he/she makes important life decisions is one of the most important things you can do to help. Information about our program is available at www.akmya.org.

To be accepted to the Academy, each Cadet is REQUIRED to have a Mentor. Mentors must be 21 or older, same gender as Cadet, not an immediate family member (not mom, dad or step-parent), and not living in the same home as the Cadet.

Please give this application to your Cadet to take with them to their interview -OR- you may fax or mail the fully completed Mentor Application with the two references for you, to our office as soon as possible, hopefully within one week of receiving this letter and no later than the start of the cycle.

You will be required to complete a Mentor Training class, either in person, via internet or distance learning packet. You will be notified of the dates of these in-person trainings for those mentors that are in reasonable driving distance of Fairbanks and Anchorage. Our primary form of contact with mentors will be via e-mail communication. You are highly encouraged to learn more about our mentor program; please visit http://www2.ngycp.org/national/resources-for-mentors/. Mentor/Post Res Coordinator Phone e-mail Fax: 907-384-6023 Jeremy Hegge 907-384-6068 [email protected] Hans Klodt 907-384-6101 [email protected] If you have any questions, please contact one of the AMYA Coordinators at the number(s) above.

□ Mentor Application

□ Release of Information

□ Mentor Job Description (Signed)

□ Mentor Questionnaire

□ State of Alaska Confidentiality of Information Acknowledgement

□ Mentor Reference (completed)

□ Mentor Reference (completed) Thank you for volunteering to mentor a youth! ** Please give the 2 enclosed reference forms about you, at the end of your application, to a neighbor, coworker, or a friend to fill out. Then please return them with your application to your Cadet --or --to an AMYA Coordinator by mail to AMYA-Mentor PO Box 5727 JBER, AK 99505 or fax to 907-384-6023**




AMYA Mentor Application- Basic Information and Release of Information for Background Check 2 REVISED 1.13.14

MENTOR APPLICATION/Release of Information for Background Check

Please Print NEATLY the following information

(Full Legal Name) Last Name

First Name Full Middle Name Date of Birth Social Security Number (required)

Gender

Drivers License # (required) DL State of Issue (required)

Maiden Name or Other Name Used: Marital Status

Spouse’s Name

Current Mailing Address (Street/Apt#/PO Box) City State Zip Code

Current Residential Address City State Zip Code

If not at current address for the past 5 years, please list Former Address City State Zip Code

Ethnicity (for statistical purposes only) please circle

__White ___Black/African American __Asian __Alaska Native/American Indian __Native Hawaiian/Pacific Islander __Multi-Racial __Other : specify ____________________ E-mail Address (required) Home Phone Number Cell Number Fax Number

Name of Cadet/Youth you will be Mentoring (please leave blank it you are volunteering to Mentor youth as needed)

Current Employer’s Name

Occupation Length of Employment Work Phone Number

Military Service (circle those that apply)

Active Reserve Retired Past Service Other: specify _______________

Branch (circle those that apply)

Army Coast Guard Air Force Marines ARNG Navy ANG

Rank Do you currently have access or valid ID for access to JBER?

YES NO Do you have your own transportation?

YES NO Do you have car insurance? YES NO Insurance Co: _____________

While participating in the Alaska Military Youth Academy activities, pictures may be taken. I grant permission to use my name and picture for the purpose of promoting, recruiting, training or news stories of the Alaska Military Youth Academy. ___Yes ___No

Explain any current offenses on your driving record: _______________________________________________ Have you ever been convicted of a Criminal Offense (found guilty or plea agreement to any misdemeanor or felony offense)? ____No ___Yes please give full details to include date(s) and location(s) (use another sheet if needed) __________________________________________________________________________________________

I understand that information gained through Cadet Records and discussions with Cadets and staff is confidential and is not to be discussed or released at any time. I further certify that all statements herein are complete and correct. I agree that Alaska Military Youth Academy may complete a background check on me. This includes a request to DMV for a list of all violations. I authorize the Police Department and Court House to furnish any information they have on record. I release the Alaska Military Youth Academy from any liability upon furnishing such information. __________________________ _______________________________ _______________ Mentor Applicant Printed Name Mentor Applicant Signature Date

AMYA Mentor Application- Mentor Job Description 3 REVISED 1.13.14

MENTOR JOB DESCRIPTION The Mentor serves as a role model and adult friend to a Cadet during the Residential and Post Residential Phases.

Working Relationship: Reports to the Alaska Military Youth Academy (AMYA) Coordinator Responsibilities: Commit to spending 12 months in aftercare (post-residential phase- the 12 months following the cadet’s graduation

from the residential portion of the program). Weekly contact with Cadet, by letter, phone call, or in person. Minimum of 4 hours contact per month or 4 contacts per month (preferably 2 of which are face to face). Total commitment is 18 months from the start of the program.

Return completed materials promptly. Complete required training(s). Commit to make weekly contact with Cadet, by mail, or in person during the 5 month residential phase. Minimum

of 4 hours contact per month, or 4 contacts per month (preferably 2 of which are face to face). Discuss and assist Cadet with setting short, med and long-term goals leading to the Cadet’s Post-Residential Action

Plan (P-RAP). Observe program policies and guidelines for mentors. Discuss violations with AMYA Coordinator. Refer Cadet to community resources if and when needed. Participate in mentor visitations and relevant activities. (Please note that if you are not in reasonable driving

distance to JBER (Joint Base Elmendorf-Richardson), you will not be required to travel for these events.) Share in informal and fun activities with Cadet. Communicate at least monthly with AMYA Coordinator. (this includes monthly reports in the 12 month post-

residential phase) Promptly inform AMYA Coordinator of any needs or problems that may arise in Cadet’s life. ***Mentors outside reasonable driving distance to Anchorage are not required to travel to JBER, however should be writing their cadet or e-mailing them at [email protected] while they are in the residential portion of the program.*** __________________________ _______________________________ _______________ Mentor Applicant Printed Name Mentor Applicant Signature Date


AMYA Mentor Application- Mentor Questionnaire 4 REVISED 1.13.14

MENTOR QUESTIONNAIRE Mentor Name (print) _______________________________ Your Cadets Name _________________________________ This is a short questionnaire that is part of the process for screening the mentors. In order to know you a little bit better, we have a few questions that we would like to ask you. We appreciate everyone’s individualities and strengths. There isn’t any right or wrong answers; we just want you to be honest and straightforward. 1. What is your relationship with the Cadet? ____________________________________________________________

2. Who referred you to be a mentor for the Alaska Military Youth Academy? __________________________________

As you are aware, this is a tobacco, alcohol and drug free program. Some of our cadets have had problems in the past with these substances. 3. Do you have a personal history of drug or alcohol abuse? Have you experienced problems with drugs or alcohol, for

example with a family member? If so, how have you dealt with it?

_______________________________________________________________________________________________

4. _______________________________________________________________________________________________

5. What is your opinion regarding underage drinking and drug use? __________________________________________

_______________________________________________________________________________________________

6. Will you insist that the Cadet refrain from smoking, using tobacco, drugs or alcohol? __________________________

7. Will you insist that the Cadet remain with you at all times while on pass? ___________________________________

8. What are your hobbies or interests? _________________________________________________________________

_______________________________________________________________________________________________

9. What languages do you speak? _____________________________________________________________________

10. Do you attend church? ___No ___Yes What church do you attend _______________________________________

AMYA is located on JBER (Joint Base Elmendorf Richardson), a secure military installation. You must have a Military ID, DOD ID, DBIDS, or other military issued ID card to access the installation. If you do not have access, please provide the following information; Driver’s License State/Number: __________________ Social Security Number: __________________________ __________________________ _______________________________ _______________ Mentor Applicant Printed Name Mentor Applicant Signature Date

STATE OF ALASKA Confidentiality of Information Acknowledgment

AMYA Mentor Application- Confidentiality of Information Acknowledgment (1 of 2) 5 REVISED 1.13.14

In performing their duties, many employees/contractors have access to confidential personal or financial information concerning state employees or entities that do business with the state. It is important that persons with access to confidential information understand their duty to maintain the confidentiality of that information.

1. I, _____________________________, am an employee, contractor, volunteer of the

Department of Military and Veteran’s Affairs/Alaska Military Youth Academy. I understand that, in performing my duties I may have access to confidential information about state employees or entities that do business with the state. I agree that I will not discuss, disclose, or cause disclosure of any such confidential information to anyone who does not have a business need and a legal right to know the information.

2. I will handle and store confidential information in accordance with state and department policy. 3. I acknowledge that I could suffer disciplinary action, including discharge from state employment,

and, in certain circumstances, face criminal penalties for revealing confidential information to someone who does not have both a business need and a legal right to know the information, or for misusing confidential information. If I do not know whether a person requesting confidential information is entitled to receive the information, I will consult my supervisor.

Examples of confidential information covered by this acknowledgement: ¾ Personnel information covered by AS 39.25.080 (see page 2), as well as information such as

social security numbers, birth dates, home addresses/phone numbers, leave balances, personnel actions, investigations, grievances, applications, appeals, or any other personnel matter, and other state business that is confidential under statute.

¾ All information that is confidential by law, including but not limited to tax matters and beneficiary programs.

¾ Information that by its nature must be secured to prevent harm to the state or its business partners, including but not limited to credit card information and vendor tax information.

Certification Statement: By signing below I acknowledge that I have read and understand the information included in this acknowledgement.

Printed Name Signature Date

AMYA Mentor Application- Confidentiality of Information Acknowledgment (2 of 2) 6 REVISED 1.13.14

Alaska Statute 39.25.080 Sec. 39.25.080. Personnel records confidential; exceptions. (a) State personnel records, including employment applications and examination and other assessment materials, are confidential and are not open to public inspection except as provided in this section. (b) The following information is available for public inspection, subject to reasonable regulations on the time and manner of inspection: (1) The names and position titles of all state employees; (2) The position held by a state employee; (3) Prior positions held by a state employee; (4) Whether a state employee is in the classified, partially exempt, or exempt service; (5) The dates of appointment and separation of a state employee; (6) The compensation authorized for a state employee; and (7) Whether a state employee has been dismissed or disciplined for a violation of AS 39.25.160 (l) (interference or failure to cooperate with the Legislative Budget and Audit Committee). (c) A state employee has the right to examine the employee's own personnel files and may authorize others to examine those files. (d) An applicant for state employment who appeals an examination score may review written examination questions relating to the examination unless the questions are to be used in future examinations. (e) In addition to any access to state personnel records authorized under (b) of this section, state personnel records shall promptly be made available to the child support services agency created in AS 25.27.010 or the child support enforcement agency of another state. If the record is prepared or maintained in an electronic data base, it may be supplied by providing the requesting agency with access to the data base or a copy of the information in the data base and a statement certifying its contents. The agency receiving information under this subsection may use the information only for child support purposes authorized under law.

Alaska Statute 39.25.900 Sec. 39.25.900. Penalties. (a) A person who willfully violates a provision of this chapter or of the personnel rules adopted under this chapter is guilty of a misdemeanor. (b) A state employee who is convicted of a misdemeanor under this chapter or the personnel rules adopted under this chapter immediately forfeits the employee's office or position.

The Alaska Whistleblower Act The Alaska Whistleblowers Act (AS 39.90.100 — 39.90.150) prohibits public employers from discharging, threatening, or otherwise discriminating against employees for reporting matters of public concern to a public body. The whistleblower protection extends to those who have made — or are about to make — reports on matters of public concern, as well as those who participate in court actions, investigations, hearings, or inquiries on matters of public concern.

A "matter of public concern" means a violation of state, federal, or municipal law, regulation, or ordinance; a danger to public health or safety; gross mismanagement, substantial waste of funds, or clear abuse of authority; a matter that the office of the ombudsman has accepted for investigation; or interference or failure to cooperate with the Legislative Budget and Audit Committee.

A "public body" means an officer or agency of the federal government, the state, a political subdivision of the state, a public or quasi-public corporation or authority established by state law, or the University of Alaska. Consequently, whistleblower protection could apply to a state employee's report to his or her own employer.

Whistleblower protection applies only when the reporting person reasonably believes that the information reported is or is about to become a matter of public concern and the person reports the matter in good faith. The protection does not apply if the matter of public concern is the result of the reporting person's own conduct, unless the reporting person's employer required that conduct.

AMYA Mentor Application- Mentor Reference Form (1 of 2) 7 REVISED 1.13.14

Mentors-please insert your name and provide this to someone who can be a reference for you.

________________________________ Mentor Applicant’s Name

Mentor Reference Form

The person named above has applied to be a volunteer mentor with the Alaska Military Youth Academy. He/she is being considered for a match in a one-to-one relationship with one of our Cadets. The information received is kept in confidence. For more information about our program please go to www.akmya.org or contact 907-384-6068 or 384-6101. How long have you known the applicant? _______ In what capacity? ________________________________ Does the applicant work well with others? ______________________________________________________ Does the applicant have a good home relationship? ______________________________________________ Does he/she have a tendency to over-commit or get too involved? __________________________________ Please rate the volunteer on the questions below: Excellent Average Poor Compassion for those in need? Concern for young people? Maturity and stability? Ability to respect others with differing views and values from one’s own? Skillfulness to express an opinion in the face of opposition? Responsibility to use confidential information appropriately? Ability to remain objective in crisis and conflict situation? Ability to problem solve and reach decisions independently? Openness to learning? Verbal communication skills? Written communication skills? Proficiency to carry out assignments in due time? Do you have any concerns about the suitability of the applicant’s ability to work with our Cadets? __________________________________________________________________________________________

________________________________________________________________________________________

Reference Printed Name ______________________________________ Date___________

Reference Signature __________________________________________ Phone_____________________

Reference Email Address: _____________________________________

Would you like to volunteer to be a mentor for the Alaska Military Youth Academy? __No ___Yes ___Need more information Reference: Please return to AMYA-Mentor PO Box 5727 JBER, AK 99505 –or- fax to 907-384-6023 -or- email to [email protected] or [email protected] .




AMYA Mentor Application- Mentor Reference (2 of 2) 8 REVISED 1.13.14

Mentors-please insert your name and provide this to someone who can be a reference for you.

________________________________ Mentor Applicant’s Name

Mentor Reference Form

The person named above has applied to be a volunteer mentor with the Alaska Military Youth Academy. He/she is being considered for a match in a one-to-one relationship with one of our Cadets. The information received is kept in confidence. For more information about our program please go to www.akmya.org or contact 907-384-6068 or 384-6101. How long have you known the applicant? _______ In what capacity? ________________________________ Does the applicant work well with others? ______________________________________________________ Does the applicant have a good home relationship? ______________________________________________ Does he/she have a tendency to over-commit or get too involved? __________________________________ Please rate the volunteer on the questions below: Excellent Average Poor Compassion for those in need? Concern for young people? Maturity and stability? Ability to respect others with differing views and values from one’s own? Skillfulness to express an opinion in the face of opposition? Responsibility to use confidential information appropriately? Ability to remain objective in crisis and conflict situation? Ability to problem solve and reach decisions independently? Openness to learning? Verbal communication skills? Written communication skills? Proficiency to carry out assignments in due time? Do you have any concerns about the suitability of the applicant’s ability to work with our Cadets? __________________________________________________________________________________________

________________________________________________________________________________________

Reference Printed Name ______________________________________ Date___________

Reference Signature __________________________________________ Phone_____________________

Reference Email Address: _____________________________________

Would you like to volunteer to be a mentor for the Alaska Military Youth Academy? __No ___Yes ___Need more information Reference: Please return to AMYA-Mentor PO Box 5727 JBER, AK 99505 –or- fax to 907-384-6023 -or- email to [email protected] or [email protected]




14-2 amya complete application

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