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PROGRAM APPLICATION
1 | P a g e TAH Application Package © 2018 Take a Hike Foundation
Take a Hike is a full-time, alternate high school program for youth who were formerly disengaged.
Embedded in the public school system, the program is offered in partnership with the Take a Hike
Foundation and community volunteers. Over the past 17 years, we have seen hundreds of students
dramatically increase attendance; expand social and emotional skills; and improve mental and physical
health and well-being. We see about 80% of our students graduate from high school.
TAKE A HIKE OBJECTIVES
Increase student attendance and engagement in school and community.
Engage students to support improvements in their own mental and physical health and well-being.
Improve academic success, leading to high school graduation.
Our ultimate is goal is to assist students to become resilient individuals who can navigate the challenges
of young adulthood after they move on from Take a Hike.
TAKE A HIKE PILLARS
From our rich classroom community, students engage
in:
Academics: students have the opportunity to complete
all courses required for a dogwood diploma.
Adventure-Based Learning: students are engaged in
experiential and land-based learning one day each
week, and during three long wilderness trips.
Community Involvement: connects students to their
community and offers them a chance to give back.
Therapy: embedded registered clinical counsellors
provide students with psychoeducational support.
PROGRAM APPLICATION
2 | P a g e TAH Application Package © 2018 Take a Hike Foundation
APPLICATION PROCESS
This application is to be filled out by the student, with the guidance of the referring adult. Each program
can accept approx. 20 students per year, with intake happening for both September and January, if
needed. Applicants will be notified by a Take a Hike staff member on next steps.
APPLICATION FOR ENROLMENT (TO BE COMPLETED BY THE STUDENT) Name Date of Birth Gender
Y/M/D
SCHOOL INFORMATION Student # PEN #
Ministry / ID #
ESL □ Yes □ No First Language
Do you have Aboriginal Ancestry? □ Yes □ No Do you identify as a visible minority? □ Yes □ No
Ministry of Education Designated □ Yes □ No If yes, designation? □ H □ R □ Q
□ In School Name of current school/program
School-based contact Tel
□ Out of School Last School attended
Last Grade completed Year
Reason for leaving
Number of days attended previous year: Number of days absent previous year: Number of courses completed previous school year:
PROGRAM APPLICATION
3 | P a g e TAH Application Package © 2018 Take a Hike Foundation
CONTACT INFORMATION
Student Phone Number
Student Email
Who do you currently live with, and what is their relationship to you?
Gender of sibling: Age
Gender of sibling: Age
Gender of sibling: Age
Gender of sibling: Age
CONTACT INFO OF PARENTS/GUARDIANS
Parent/Guardian Name: Relationship to you:
Address (please include postal code): Home #:
Cell #:
Work #:
Email Address:
Parent/Guardian Name: Relationship to you:
Address (please include postal code): Home #:
Cell #:
Work #:
Email Address:
PROGRAM APPLICATION
4 | P a g e TAH Application Package © 2018 Take a Hike Foundation
Guardian’s Name: Address (please include postal code): Home #:
Cell #:
Work #:
Email Address:
Other: Address (please include postal code): Home #:
Cell #:
Work #:
Email Address:
OUTSIDE AGENCY INVOLVEMENT Do you have contact with the Ministry for Children and Family Development? □ Yes □ No
Do you have a (please circle those that are relevant)?
Social worker / PO Officer / Counsellor / Therapist / Psychiatrist / Psychologist
If yes, please provide email and phone information:
Name _______________________Tel __________________ Email__________________________
Name _______________________Tel __________________ Email__________________________
Name _______________________Tel __________________ Email_________________________
What other community support agencies do you have contact with? ______
PROGRAM APPLICATION
5 | P a g e TAH Application Package © 2018 Take a Hike Foundation
MEDICAL AND HEALTH FORM
Student Full Name
Birthdate
Address
Doctor Tel
Any health concerns?
BC Medical Number _____________________ Date of last tetanus shot ___________________
Any Additional Insurance?
Do you take prescribed medications (include EPI pens)? □ Yes □ No
If yes, please list: (name, reason, dosage, storage, potential side effects/treatment of such):
Name Reason Dosage/Timing/Special
Instructions
Potential Side Effects
Allergies (ie, food, bee stings):
Please List: Reaction:
PROGRAM APPLICATION
6 | P a g e TAH Application Package © 2018 Take a Hike Foundation
***OFFICE USE – fill out with TAH staff member in Intake Meeting
Storage Requirements:
Potential side-effects:
SERIOUS
COMMON
First Aid for side-effects:
Contradictions:
Who will carry:
Who will administer:
Dentist ___________________________________ Tel_________________________________
Have you had a concussion before? □ Yes □ No
If yes, please explain:
Do you have any health concerns or previous injuries, surgeries, hospitalization that Take a Hike staff
should know about? □ Yes □ No
If yes, please explain: ________________________________________________________________
PROGRAM APPLICATION
7 | P a g e TAH Application Package © 2018 Take a Hike Foundation
Specify activities that this student should no participate in, or modifications that might be required to
participate in field studies
Other Health/Medical/Dietary Concerns/restrictions:
Emergency Contacts
1) Phone: (H) (W) (C)
2) Phone: (H) (W) (C)
ACKNOWLEDGEMENT OF CONSENT*
Specify Parent/Guardian relationship who is participating in filling out and signing this form:
Should it become necessary for my child to have medical care, I hereby give the teacher permission to
use his/her best judgement in obtaining the best of such services for my child. I understand that any cost
will be my responsibility. I also understand that in the event of illness or accident, I will be notified as
soon as possible via the emergency contact information listed above.
Name (please print) Signature
*More discussion and info on this in Intake Interview. Please feel free to wait to sign this until speaking
with a staff member.
PROGRAM APPLICATION
8 | P a g e TAH Application Package © 2018 Take a Hike Foundation
Please have your referral source (high school counselor/youth worker) fill out the next section: School Name __________________________________________________________________________
(School) Counselor Name ________________________________________________________________
Phone Number(s) ______________________________________________________________________
Email Address _________________________________________________________________________
Please describe your relationship to this student:
Based on your understanding of the TAH program (information included in this application package, on
the website or through interaction with program), would TAH be a suitable program for this student?
Please explain why ‘yes’ or ‘no’:
Does this student have a school designation? If yes, please list - ________________________________ Please list documentation found in student file supporting the designation (ie: School Team Minutes, Attendance Records, Behavioural/Mental Health Assessments etc):
Can a Youth and Family Worker from Take a Hike contact you with further questions?
Please circle - YES / NO
PROGRAM APPLICATION
9 | P a g e TAH Application Package © 2018 Take a Hike Foundation
TAKE A HIKE CONSISTENCIES These ground rules have been adopted to ensure safety, maximum participation, and optimal learning in
the classroom and on fieldtrips.
BE ON TIME AT THE START OF THE DAY, AND FOR ALL BREAKS: If you cannot make it on time;
call ahead and leave a message telling us when you will arrive.
RESPECTFUL LANGUAGE: Swearing and put downs are disrespectful and do not belong in the program.
Please express yourself in a pro-social way.
FOCUS: We seek to create an environment that everyone’s voices can be heard and respected. It’s
important to pay attention to the activity and speaker at hand. Staff desire to hear your input and
understand your thoughts and feelings, and will designate time in all activities to give you full attention,
should you need it.
KEEP THE CLASSROOM/CAMP GROUND CLEAN: The classroom and campground are shared by many.
We strive to create and maintain environments that can and would be enjoyed by others.
MUSIC and/or ELECTRONIC DEVICES: Cell phones, mp3 players, iPods, games, etc may NOT be used
during class time, day trips, or multi-day trips.
ABUSE OR VIOLENCE OF ANY KIND: Abuse is defined as anything that is destructive or disrespectful to
self or others. Abuse includes: swearing, sarcastic tone of voice, or loud aggressive tone
Anti-social behaviour such as: racism (including jokes), sexism (any comments which put people
down based on their gender), homophobia (comments about a person’s sexual orientation) Violence is
any physical act which hurts self or another. It includes: Pushing, spitting at another, hitting, scratching,
kicking, etc
RELATIONSHIPS: We strive to create a community where everyone feels welcome. We do this through
creating caring individual friendships, and a cohesive group dynamic.
LEAVING THE CLASSROOM/FIELDTRIP/CAMPGROUND: You must check with a staff person before you
leave for any reason (including bathroom breaks).
NO SMOKING ON SCHOOL GROUNDS OR FIELD TRIPS: Staff will let you know when and where smoking
is permitted.
PROGRAM APPLICATION
10 | P a g e TAH Application Package © 2018 Take a Hike Foundation
FAMILY PARTICIPATION: We understand that parents are the experts on their children, therefore
parental/guardian involvement is crucial for student success in the program. Participation from family
occurs through participation in the students academic and therapeutic process. Should you have
concerns about your child’s performance, staff will make every effort to meet with you.
A field trip starts when you enter the school grounds and ends after clean-when the staff indicates
that the day is complete. These hours may vary on different days.
Student Declaration: I am prepared to attend regularly, to make a commitment, to complete all
assigned work, and to participate fully in all program activities, regardless of the weather. I have read,
understood, and agree to abide by the expectations set by the Take a Hike program.
Signature of Student ______________________________________ Date _________________________
Guardian Declaration: I am fully prepared to support the above student to succeed in this program by
liaising regularly with staff and attending parent/staff meetings as required.
Signature of Guardian _____________________________________ Date _________________________
Signature of Guardian _____________________________________ Date _________________________
PROGRAM APPLICATION
11 | P a g e TAH Application Package © 2018 Take a Hike Foundation
Lastly, please share with us in a short paragraph why you would like to join the Take a Hike program:
PROGRAM APPLICATION
12 | P a g e TAH Application Package © 2018 Take a Hike Foundation
Program and Intake Contact Info:
Burnaby Take a Hike
Grades 10-12
Canada Way Learning Centre
5310 Woodsworth Street, Burnaby BC V5G 1S4
Peter Van Den Hoogen 604-760-0141
Vancouver Take a Hike
Grades 10-12
John Oliver Secondary School
530 East 41st Ave, Vancouver BC, V5W 1P3
Grades 10/11: Adriann Connor 604-713-8255 (available Sept-June)
Grades 11/12: Jay Wade 604-713-8243 (available Sept-June)
West Kootenay Take a Hike
Grades 10-12
Kootenay Columbia Learning Centre
200 Third Ave. Trail BC, V1R 1R6
(serving communities of Castlegar, Fruitvale, Robson Valley, Rossland, Montrose, and Trail)
Chris Gibson 250-364-1275 (available Sept-June)
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