The prevention team at TAASA is proud to announce that the 2014 Break the Box Youth Summit

will take place June 22-24 at Texas State University in San Marcos. The theme for this years
summit is No Boxes, No Limits. The summit will also have a different structure and purpose
this year.. We will be selecting up to 25 youth from across the state of Texas to explore the
negative impact of gender stereotypes and to help develop school and community-based
strategies for breaking the gender boxes that limit our potential. These strategies will inspire
the creation of the Break the Box Week Toolkit that will serve as a guide for schools and
communities that want to challenge gender stereotypes in Texas.

We are looking for youth, age 14-18, who are thoughtful, creative, and passionate about
making Texas a better, safer place for everyone. The application process is as follows:

Submit application (see below) to Ted Rutherford by 5pm on Friday, June 6.
Submissions can be sent via fax at 512.474.6490 or email at trutherford@taasa.org
If you are accepted to participate in the summit, we will notify you by June 11 and you
will be sent a registration packet by email to complete and return.
Those who are not accepted will be notified by email by Friday, June 13.
Registration packets must be completed and returned no later than Monday, June 16

***You are not required to have an adult chaperone. If you will have one, that person needs
to complete the Adult Chaperone application on page 4 of this packet.

YOUTH APPLICATION
FIRST NAME: ______________________ LAST NAME: __________________________________
AGE: _____________ EMAIL ADDRESS: ______________________________________________
PHONE (with area code) Cell: ______________________ Home: _____________________
BEST WAY TO REACH YOU (circle one): call cell call home text me email me
T-SHIRT SIZE (circle one): SM M LG XL 2XL 3XL 4XL OTHER ___________
*GENDER (for rooming purposes): ___________________________________
*ROOMS ARE TYPICALLY DOUBLE OCCUPANCY WITH SAME GENDER PEERS. IF YOU WOULD LIKE TO REQUEST
A PRIVATE ROOM OR OTHER ACCOMODATIONS, PLEASE EXPLAIN IN THE SPACE PROVIDED BELOW:






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Please read and answer the following question in 250-750 words.

A stereotype is a belief about all people with a particular characteristic (such as
gender, race, sexual orientation, and so on) that is often untrue and unfair. Describe
some examples of stereotypes based on these things that you have witnessed in your
school and talk about the negative impact those stereotypes have had on your school
or the people in it. (FEEL FREE TO USE THE BACK OF THE PAGE IF YOU NEED IT)




ADULT CHAPERONES

We will not be providing an adult track as we have done in the past. Instead, adults will serve
as chaperones to the youth attendees. Chaperone responsibilities are as follows:

Coordinate all paperwork for youth that you are bringing to the summit
Assist with check-in and check-out process for your group
Serve as holder of the electronic access card for your group
Accompany youth attendees during all meals provided at the summit
Participate in evening/night time social activities on Sunday and Monday nights

Youth participants will be in session for large blocks of time during the day on Monday and
Tuesday. While the youth attendees are in session, you will have two options for spending
your time. Those options are as follows:

OPTION 1 Audit a facilitation workshop
TAASAs prevention team is conducting in-depth facilitation training for prevention
educators that are part of our curriculum pilot project. We will take participants
through a series of activities designed to help folks develop and improve their skills in
areas such as facilitating open dialogue, unpacking participant statements, handling
conflict during sessions, and facilitating group guidelines. Participants will also have
ample opportunity to share their successes and struggles and practice giving and
receiving constructive feedback on implementing the skills they learn and/or refine
while at the training.

As an auditor, you will be able to fully participate in the workshop with the exception of
opportunities for getting constructive feedback on your facilitation. Participants will
be given an opportunity to practice facilitating particular activities in front of an
audience. During this part of the workshop, you will serve as audience member only.

OPTION 2 Enjoy some free time
If you are not interested in auditing the facilitation workshop, you will be free to do
what you like during the blocks of time you are not required to be a chaperone. You
are allowed to leave campus, if you choose, provided you return in time for your
chaperone duties. Please note that you are on call in case of emergency and will
need to return to campus immediately should an emergency situation arise.

Some things to note:
Youth are not allowed to leave campus at any time between check-in and check-out.
Once you choose your participation option, we ask that you stick with it. If you decide
to audit the facilitation workshop, we ask that you fully commit to it from beginning to
end.
All chaperones will be subjected to a background check prior to the summit.
Meals and lodging are provided at no cost to you at Texas State. You are responsible
for your travel expenses to and from the event.
Youth can attend the summit without an adult chaperone. All adults that attend the
summit, including TAASA staff, will serve as chaperones to any unaccompanied youth.



ADULT CHAPERONE APPLICATION

FIRST NAME: ______________________ LAST NAME: __________________________________
EMAIL ADDRESS: ______________________________________________
PHONE (with area code) Cell: ______________________ Home: _____________________
BEST WAY TO REACH YOU (circle one): call cell call home text me email me
T-SHIRT SIZE (circle one): SM M LG XL 2XL 3XL 4XL OTHER ___________
*GENDER (for rooming purposes): ___________________________________
*ROOMS ARE TYPICALLY DOUBLE OCCUPANCY WITH SAME GENDER PEERS. IF YOU WOULD LIKE TO REQUEST
A PRIVATE ROOM OR OTHER ACCOMODATIONS, PLEASE EXPLAIN IN THE SPACE PROVIDED BELOW:






NAMES OF YOUTH YOU ARE ACCOMPANYING

1.
2.
3.
4.








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TAASA
Service Key Codes
Check One please

Level 1

County Criminal

Authorized Agent Signature
Date and Time Sent: Date________________ Time _________

APPLICANT NOTIFICATION

Please print legibly and provide all information requested.

APPLICANTS LEGAL NAME:
Last Name First M.I.


SOCIAL SECURITY #:


CURRENT HOME ADDRESS:
Street City/State Zip

DATE OF BIRTH: DRIVERS LICENSE #: STATE OF ISSUANCE:
Month/Day/Year

DAYTIME PHONE #: EVENING PHONE #:


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APPLICANT CONSENT I understand and agree that LS Screening LLC will verify all or part of the information I have given my
prospective employer. I understand that this verification may include an inquiry into my credit history, criminal and civil records
felony & misdemeanor and deferred adjudication records, prior employment (including contacting prior employers), education
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during my employment, with or without cause and at their sole discretion, conduct additional investigations including any and/or
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