'Break the Connection'

It seems pretty random at first.

His smoking. Her asthma.

Teen movies. Movie stars smoking for no reason.

Sweet-flavored chew. For tough guys?

The more you look, the more you see something.

A connection between tobacco and the harm that happens to everyone around it.

Between Big Tobacco and deadly lies.

It¹s up to those of us who see the connection to expose it.

It¹s up to us to break the connection.

The 2010 JEL Summit is finally here and you are invited! Sign up for this year’s Break the Connection JEL Summit for 3 days of learning, friends, and fun! Don’t necessarily know what goes on at the Summit? Check out the Summit Rewind video below for a recap!

Click Continue below to fill out this online application and be on your way to help Break the Connection at the 2010 JEL Summit! If you prefer to fill out a paper copy, you can download it here.

This year’s summit theme is BREAK the Connection. Knowledge about tobacco is not enough; WE need to take ACTION to achieve our goals! This year’s summit will focus more on Actions you can take than ever before. You should plan on Chanting, Marching, Painting, Talking, “DOING” more JEL activities than at any other summit.

We are dividing summiteers into two groups based on how much you know about tobacco/JEL. Below you will find descriptions of the two different groups that you can join.

Please select the Group that would best fit your experience with JEL and fighting Big Tobacco 

Rookie: If you are new to JEL or haven’t been to a summit join this group. This group is also for JEL members who aren’t extremely familiar with the program, and still need to review the basics. We’ll give you what you need to know to fight Big Tobacco and be a JEL superstar!
Veteran: This group will go into the details that, those of you who’ve been in JEL for a while, might not know. We will spend more time advocating rather than with general knowledge and the basics. If you think you’ve heard it all before or if you were in the intermediate group at last year’s summit check out our group.

You may copy and paste your essay here:

Or

You can upload your essay or project here:

Projects and essays become the property of JEL and will not be returned.

If you cannot submit your project on this page, please contact Garin and info@jeliowa.org

Youth Code of Conduct

Participant's Name:

• No drugs, alcohol, tobacco or weapons!
  The possession and/or the use of weapons, tobacco products, alcoholic beverages and illegal drugs, or remaining in the presence of individuals who are using or taking these items, within the time frame of the annual summit, are prohibited.
  
  
• Be Friends but not BF/GF!
  Inappropriate physical contact which occurs within the time frame of the annual summit is prohibited. [Inappropriate is subjective but JEL staff have the final say. As a rule, if you wouldn’t do it in front of your grandma it is probably not appropriate for the JEL summit]
  
  
• Be Nice!
  Bullying and harassment by any means, (including verbal, non-verbal, physical, written, or electronic conduct) which creates an objectively hostile environment is prohibited.
  
  
• Keep it Legal!
  Any behavior that violates any of the laws of the United States or the State of Iowa or any local ordinance is also prohibited.
  
  
• Be On Time!
  Your punctual attendance at scheduled events is considered mandatory at the annual summit.
  
  
• Don’t Break Stuff!
  All participants are expected to show respect for other’s property and the facility in which any event is being held.
  
  
• Be Helpful!
  By attending the summit you agree to serve as a contact and resource person in your community tobacco education program.
  
  

Important Notice

I, , agree to abide by this Code of Conduct and am aware that any infraction of the Code will result in my parent/guardian (s) being notified and that I may be sent home at my parent/guardian’s expense.

Particpant Signature:	Parent/Guardian Signature:
Date:	Date:

Parent/Guardian: By signing this Code of Conduct you agree to be responsible to transport your youth from the summit if he/she has broken this code or is in any other way unable to continue to attend the summit.

• You do not have to take the bus to the summit, contact the JEL Coordinator 515.281.4299 for information about driving to the summit.
  
  
• Bus transportation is FREE. You are responsible for getting to the bus stop (we try to have a bus stop within 30-45 minutes of everyone.)
  
  
• JEL will send you more information about when and where to meet the bus by June 4, 2010. Please check back to the JEL webpage often for more bus information.
  
  
• If you have any questions, please contact Garin at 515.281.4299.

Bus	Area - Route
1.	Northwest Iowa Sheldon, Spencer, Algona, Fort Dodge, Des Moines
2.	Western Iowa Le Mars, Sioux city, Holstein, Denison, Carroll, Adair
3.	Southwest Iowa Missouri Valley, Council Bluffs, Glenwood, Red Oak, Creston, Osceola, Chariton
4.	South East Iowa Ft Madison, Burlington, Mt Pleasant, Ottumwa, Oskaloosa
5.	Eastern Iowa Clinton, Cedar Rapids, Iowa city, Newton
6.	North Eastern Iowa Dubuque, Manchester, Waterloo, Marshalltown
7.	Northern Iowa Decorah, Charles City, Clear Lake, Ames

Participant's Name: 

I hereby request and consent that my child or ward be permitted to participate in 2010 ‘Break the Connection’ JEL Summit, June 17-19 at Central College in Pella, Iowa.

I undertand and agree to the following:

• The purpose of JEL is to educate students about the tobacco industry, tobacco prevention, the JEL campaign, and other tobacco-related issues. My child or ward may be exposed to graphic images involving the consequences of tobacco use as a part of this event.
• My child or ward may be transported by employees of his/her school, the Iowa Department of Public Health or other officials, employees, agents, or volunteers I may also make arrangements for my child or ward to ride with one of their school friends.
• In consideration of my child or ward being allowed to participate in the 2010 ‘Break the Connection’ JEL Summit, I hereby release from liability and agree to indemnify and hold harmless the State of Iowa, the Iowa Department of Public Health, and their officers, employees, and agents from any claim or cause of action arising out of and related to any injury, loss, damages or other liabilities that may occur as a result of my child or ward’s participation in the 2010 ‘Break the Connection’ JEL Summit.
• I authorize any official, employee, agent, or volunteer to consent to emergency medical treatment as necessary for the health and safety of my child or ward. I further agree that no official, employee, agent, or volunteer will be held responsible for injuries or damages arising from the provision of any such emergency medical treatment. I do hereby agree to indemnify and hold harmless the Iowa Department of Public Health, other sponsoring agencies, and the Department and other sponsoring agencies’ officials, employees, agents, and volunteers from any and all liability, damage, loss, claims, or demands whatsoever, including attorney’s fees, which arise out of or are in any way connected with the provision of such emergency medical services.
• I grant permission for my child or ward to appear in person or in voice, video, or photographic presentation for radio, television, electronic or print media reports and/or media campaign(s) resulting from participation in the 2010 ‘Break the Connection’ JEL Summit.
• I allow him/her to complete confidential or anonymous surveys and participate in interviews for evaluation purposes.

Participant Signature:	Date:
Parent or Guardian Signature	Date:
Parent or Guardian Name:

Medical Release Form

Participant Name:          Date Of Birth:

Is the minor listed above allergic to any food or medications?

YesNo

Please list any medications the minor is currently taking the dosage and time to be taken:

Medication Dosage Time Taken

Please list any medical condition or special needs of which staff should be aware:

Emergency Contacts
Primary:		Secondary:
Name:		Name:
Phone Number:		Phone Number:
Alternate Number:		Alternate Number

On rare occasions, an emergency requiring hospitalization and/or surgery develops. As a general rule anesthesia may not be administered to or operation performed without written permission by the parents or guardians. Therefore, in order to prevent a dangerous delay, if an emergency does occur and we are unable to contact the parents or legal guardian, the parent/guardian is asked to sign the release form below.

In the event of injury or illness to my son/daughter/ward, ,  I hereby authorize any official, employee, agent, or volunteer to secure whatever treatment is deemed necessary and, if recommended by an emergency physician, the administration of an anesthetic or surgery. I further authorize summit staff to contact my child/ward’s physician / dentist if necessary during the summit, June 16-18 2009. I give permission for my child/ward’s physician/ dentist to share medical information with summit staff during the summit.

Parent or Guardian Signature

Parent or Guardian Name:

Date: