Teen Samurai Orientation Questionnaire

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Welcome

Thank you for choosing to participate in the ChoiceCenter Teen Samurai Game®! It is our honor to work with young people who, like you, are committed to moving forward in their lives as leaders. You have dedicated yourself to an important educational experience, and an exciting journey awaits you.

The information given and requested on this form is designed to provide you with some practical details about the structure and process of the training as well as to ensure that your choice to participate is clear and informed. It is also designed to provide ChoiceCenter with information that will assist us in serving you appropriately. This form should help answer any questions you may have and may also help clarify your objectives.

Please read this form in its entirety with your parents, and have them sign in the designated areas. Your forms must be completed and returned to ChoiceCenter within 72 hours of registration. If you have questions or require clarification about any of the material presented here, or the format of the training, please call ChoiceCenter at (702)838-3988. Completed forms may be faxed to (702) 926-4999.

We believe that after completing this form and the attached homework, you will have a broader perspective as well as a clearer idea of your personal goals and objectives. This will assist you in maximizing the value available from the training and ensure this value is carried forward.

Welcome to the ChoiceCenter Teen Samurai Game®. It is our privilege to serve you!

The Team at ChoiceCenter
702-838-3988

'The dream is not up there in the sky or the stars, it’s right here in your heart.”
-Dan Zadra

TRAINING SCHEDULE

Attendance at the full weekend and two weeks of personal coaching are required to attend:

 

FRIDAY:

Workshop begins

7:00 PM

Ends approximately

10:00 PM

SATURDAY:

Workshop begins

10:00 AM

Ends approximately

 9:30 PM

SUNDAY:

Workshop begins

10:00 AM

Parent Graduation

 6:00 PM

 

Students will have coaching calls for the two weeks following the training weekend.

About Your Participation

  The Teen Samurai Game® provides a distinctive learning approach in which participants engage honestly, directly and effectively with issues at the heart of their lives. The Training addresses all dimensions of human nature:
intellect, emotions, body and spirit.

  The ChoiceCenter Teen Samurai Game® is an experiential learning program that calls for your full and committed participation. The program includes the following types of activities:

Interactive Discussions

The trainer will present various topics relevant to issues that typical teenagers face. This includes: Keeping Commitments; Making Choices; Responsibility vs. Blame; Dreams and Goals; Effective Communication; Self-Esteem; Contribution and
Team Work; Relationships; and Leadership. In these discussions the trainer will discuss a particular point of view about these subjects. The purpose is not for you to agree or disagree with what is said, but rather to assist you in observing
how you relate to these particular subjects. In observing yourself in the training, you can learn about your principles, commitments, and relationships.

Sharing

Throughout the training you will have the opportunity to learn about yourself through communication: speaking about what you are learning, and listening to the experiences of others. Such sharing occurs one-on-one, in small groups, or in
front of the entire training group.

Small Group Exercises

At the start of the training you will choose a small group with an average of 6-8 other participants. During the training, you will meet with your small group to discuss and share what you are learning as well as to participate in other experiential
exercises. A volunteer staff member will act as facilitator for your group.

Personal Coaching

At times you may have direct interaction with the trainer. The trainer will relate to you from the perspective that you are capable of effectively handling the circumstances in your life and that you are committed to extraordinary accomplishments.
The trainer will also ask you to take personal responsibility rather than being powerless in the face of life's obstacles. Interactions with the trainer is an opportunity for you to examine the limitations of your world view, therefore you
may feel challenged, anxious or uncomfortable in going outside of your comfort zone.

Games

You will, as part of a group, play games to reveal the competitive and cooperative strategies you use, and also to illuminate the possibility of meeting both group and individual commitments throughout your life.

 

Closed-Eye Processes -

During a closed-eye process the trainer will guide you through a creative visualization. Frequently music and the lowering of lights are used during these processes to facilitate relaxation and promote creativity.

Insight and Discovery Homework

At the close of each day you will be given a homework assignment to be completed before the next session begins. The homework is designed for you to continue your discovery, bring greater clarity to what you are learning, and prepare you
for the next day's session.

Declarations and Action Planning

On Sunday of the training, you will write short and long-term goals and identify actions you can take that will support you in reaching them. This is an opportunity to get coaching and feedback on how you can use the tools that you have learned
over the weekend to meet your goals everyday.

Food and Rest

  During the 3-day weekend, it is important that you get sufficient rest and food. Every 2 to 4 hours there will be a 15-30 minute break and on Saturday for approximately 1-1/2 hours in the late afternoon a dinner meal will be provided.
Be sure to eat a sustaining meal each day before coming to the training. You may need to adjust your schedule to be assured of getting sufficient sleep. This is your personal responsibility. Without sufficient food and rest, your training
experience will be diminished. Please arrange your schedule accordingly.

Ground Rules

  Important aspects of every organization, activity, or game are defined in its rules. The following ground rules are integral to the success of the Teen Samurai Game®. They will be presented to the entire training group on
Friday evening of the training.

1. Maintain confidentiality of other participants' experiences. In order to preserve spontaneity, do not discuss or disclose the experiential parts of the training with someone who has not taken the Teen Samurai Game®. Please note: ChoiceCenter
cannot guarantee confidentiality.

2. Be on time. During the weekend, the workshop starts on Friday at 7:00 PM, at 10:00 AM on Saturday, and 10:00 AM on Sunday.

3. Attend the entire weekend, and participate during your coaching for the two weeks following.

4. Do not side talk. Ask questions, talk and share only when acknowledged by the trainer or during designated sharing periods.

5. Do not smoke, eat, chew gum, or drink beverages inside the training room. Bottled water is the only exception.6. No alcohol, marijuana, or other non- prescription mood altering drugs are to be used either in or out of the training through the completion of Sunday of the session.

7. Be responsible for your well being. This includes getting sufficient food and sleep during the training, and taking any prescribed medications on schedule.

8. Wear your nametag in a visible location during training hours. Turn in your nametag before meal breaks and at the end of each day.

9. Turn off and remove all cellular phones and pagers before entering the training room.

 

Recommendations:

1. Sit in open body position.

2. Be sensitive to when you leave the room to use the bathroom.

3. Respect other users and the physical plant of this facility.

The Four Pillars of Leadership

Integrity

Commitment

Contribution

Responsibility

The ChoiceCenter Teen Samurai Game® expects all students will voluntarily participate, come prepared to put forth their best effort, try new activities, work as part of a team and follow instructions.

As mentioned above, the ground rules will be reviewed, explained and agreed upon Friday evening.

I have read the information within this packet and understand and agree to participate in the training.

Confidential Health Information

Please answer all of the following questions completely. Your answers will be kept confidential. The information you provide here will enable our trainers and staff to better support your participation. Our goal is to invite all students, individually and collectively as a group, to participate fully. This may include interpersonal reflection, choices about the past, and commitments to the future and group / team challenges. Although lead and assisted by a trainer and volunteer staff, it is not possible for ChoiceCenter to predict any team challenges. if you have any questions about the appropriateness of your participation at this time, please consult a trained professional. In some cases, as instructed in the next section of this form, we require that you do so in order to participate in the training.
Important: If you answered “Yes” to questions 2 or 3 above, and “No” to questions 4 and 5, read and follow the directions in Section A&B.
If yes, you are not permitted to participate in the Teen Samurai Game®. We recommend and sincerely encourage you seek appropriate support.

Emergency Contacts

Must have two contacts with complete information. In case of emergency contact (please print):

Verification

I hereby acknowledge and attest that I am over age 18 and have thoroughly and carefully read the information contained herein. I understand it, and my child and I have answered all of the questions fully and truthfully. I take full responsibility for my child’s participation in the ChoiceCenter Teen Samurai Game®. I understand that my child will not be able to take the training without all forms and necessary signatures completed.

YOUR COMPLETED FORM IS THE PROPERTY OF CHOICECENTER LEADERSHIP UNIVERSITY

HOLD HARMLESS, DISCLAIMER, RELEASE AND ARBITRATION AGREEMENT

Training: TEEN SAMURAI GAME
hereinafter collectively “ChoiceCenter Leadership University” and “you” representing the “named minor child”. If you are in complete agreement with all the terms set forth below, initial each and every provision in the space provided to indicate that you have read and fully understand it. Then sign and date this form.

SECTION I: CONSENT TO PARTICIPATE

I am fully informed to my satisfaction about the ChoiceCenter Leadership University TEEN SAMURAI GAME® WORKSHOP.

to participate in the training at this time.

SECTION II: AGREEMENT RELEASING LEGACY FROM LIABILITY FOR ITS NEGLIGENCE OR OTHER ACTS

In consideration of ChoiceCenter Leadership University allowing the named minor child to attend and participate in the TEEN SAMURAI GAME® and its associated activities, I, (Parent)
, myself, my heirs, executors, administrators, and assigns, hereby agree:

Section III: INSURANCE DISCLAIMER, ARBITRATION AND ADDITIONAL PROVISIONS

I HAVE CAREFULLY READ THIS AGREEMENT AND I UNDERSTAND ITS CONTENTS. I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER, AND SIGN THIS AGREEMENT OF MY OWN FREE WILL AS THE PARENT, LEGAL GUARDIAN OR ASSIGNED CARETAKER FOR THE NAMED MINOR CHILD. I FURTHER CERTIFY THAT I HAVE RECEIVED A COPY OF THE AGREEMENT.

TEEN QUESTIONAIRE (Completed by Student)

To prepare yourself to get maximum value from the Teen Samurai Game® Workshop, please answer the following questions honestly and in detail. Be specific! This is an opportunity for you to begin looking at some of the topics and/or issues we will be working with in the training. You may attach sheets if needed. All of your responses will be kept confidential.

PARENT QUESTIONAIRE (Completed by Parent or Guardian)

Please answer the following questions honestly and thoroughly. Be specific. Feel free to attached additional pages if needed. Your responses will be kept completely confidential.
* Required