YWLA Adult Recommendation/Commitment Form

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The Young Worker Leadership Academy. Presented by LOHP-UC Berkeley, LOSH-UCLA and the Commission on Health & Safety and Workers' Compensation. The 2021 YWLA will be held virtually from Thursday, March 4, through Saturday, March 6th, 2021.

Adult Advisor Name *

Title

Agency/ Organization *

Gender

Address *

City/ State/ Zip *

Work Phone *

Cell Phone *

Email *

Date of Birth *

YYYY

Applications for the following youth have been submitted: (Please list names of 4 youth + 1 alternate) *

Where did you learn about the Academy? *

Attending the Academy

As an adult recommending a youth team to attend the Young Worker Leadership Academy, please check off the boxes below acknowledging that you have reviewed the following items and that you and the youth understand the requirements and benefits of participating in the Academy. An adult sponsor must agree to accompany the team and to support them in planning and conducting their team project.

Yes, I have discussed this Academy with the youth team I am recommending and have reviewed their individual applications. They understand that the Young Worker Leadership Academy will pay for a two-night hotel stay and meals (except for lunches) and will provide a $50 stipend after completion of their community action/ project on workplace health and safety issues.

I understand that you will cover the cost of accommodations for two nights, and meals (except for lunches) for one adult sponsor for the team.

Yes, the youth I am recommending have indicated they able to make arrangements to miss school on Thursday ( as necessary) and Friday. The Academy will begin at 1pm on Thursday and end at 4pm on Saturday.

Yes I have support from my supervisor, organization/school, and parents (of the youth) to complete the project AFTER the YWLA. They are aware of our goals and commitment for this Academy in developing a community team project on workplace health and safety issues.

Yes, my organization will provide a place to meet and at least 20 hours of oversight for our team to plan and implement an educational event or other activity during Safe Jobs for Youth Month, May 2019. I understand that my organization will recieve a $150 stipend for the activity as well as technical support.

Yes, I have recruited a 5th student in case an emergency happens where one of the team members cannot attend the Academy and/ or complete the team project.

Yes, I have recruited an alternate Adult Advisor, who will take on the role of the Adult Advisor if I am no longer able to commit to the YWLA and/ or project during or after the Academy. S/he will take full responsibility and will continue with the team and their team project.

Required

I understand that limited travel stipends are available. Our team: *

Will not need a travel stipend

Will need a partial travel stipend

Will need a full travel stipend

Estimated Travel Expenses: *

Alternate Adult Advisor Name *

Title

Agency/Organization *

Gender

Address *

City/State/Zip *

Phone *

Email *

Date of Birth *

YYYY

Statement

Please make a brief statement about the team of youth you are recommending the Academy and why they will be valuable and effective contributors to your community in promoting workplace health and safety through a team project. Please briefly describe your role and interest in this Academy and how your organization and staff will support the team you are recommending e.g. school/ work, schedules, meeting space, etc.

Please add your statement below: *

Please submit all forms by 5pm on December 4, 2020.

If you have any questions or concerns please email elisha.jaeke@berkeley.edu.

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