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Summersummitapp

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Summersummitapp Document Transcript

  • 1. University of California, San Diego Student-Initiated Access Programs and Services SIAPS SUMMER SUMMIT 2009 August 21-23, 2009 APPLICATION Please submit the entire application by Friday, July 31st, 2009 All applications will be considered, but priority will be given to those received by the deadline. FAX TO: (858)534-7204 ATTENTION: SUMMER SUMMIT PROGRAM FULL NAME – LAST FIRST MIDDLE INITIAL NICKNAME ADDRESS CITY, STATE, ZIP CODE PHONE NUMBER(S) DATE OF BIRTH EMAIL GENDER ETHNICITY / RACE HIGH SCHOOL GRADE CITY DISTRICT VOLUNTEER EXPERIENCE / EXTRA-CURRICULAR ACTIVITIES - PLEASE LIST ACTIVITIES (ORGANIZATION(S) AND OTHER) AND BRIEFLY DESCRIBE YOUR INVOLVEMENT WORK EXPERIENCE UCSD Summer Summit 2009 Student-Initiated Access Programs & Services (SIAPS) a component of S.P.A.C.E.S. Phone: 858-534-7330 | Fax: 858-534-7204 | E-mail: siaps@ucsd.edu 9500 Gilman Dr. #0062 La Jolla, CA 92093-0062
  • 2. UCSD SIAPS SUMMER SUMMIT APPLICATION – PAGE 2 FULL NAME – LAST FIRST MIDDLE INITIAL PLEASE CHECK ALL THAT APPLY: I HAVE PARTICIPATED IN A PRE-COLLEGIATE PROGRAM:  AVID  TRIO / TALENT SEARCH  CAL-SOAP  UPWARD BOUND  EARLY ACADEMIC OUTREACH PROGRAM (EAOP)  OTHER: ___________________ MY TUTOR/MENTOR IS: I HAVE ATTENDED/PARTICIPATED A UCSD HIGH SCHOOL CONFERENCE / OUTREACH PROGRAM SPONSORED BY UCSD:  APSA (ASIAN & PACIFIC-ISLANDER STUDENT ALLIANCE)  API LEADERSHIP RETREAT  BSU (BLACK STUDENT UNION  CAL-SOAP  KP (KAIBIGANG PILIPINO)  COMIENZA CON UN SUENO  MECHA (MOVIMIENTO ESTUDIANTIL CHICANA Y CHICANO  DARE TO DREAM DE AZTLAN)  AN EVENING WITH UC SAN DIEGO  MUSLIM STUDENT ASSOCIATION (MSA)  TRIO  QPOC (QUEER PEOPLE OF COLOR)  UPWARD BOUND  VSA (VIETNAMESE STUDENT ASSOCIATON)  OTHERS: __________________________ WOULD YOU BE INTERESTED IN ATTENDING A UCSD HIGH SCHOOL CONFERENCE DURING THE COMING SCHOOL YEAR?  YES NO IF SO, WHICH ONE(S)? AFTER HIGH SCHOOL, I PLAN TO… [PLEASE NAME THE COLLEGES/UNIVERSITIES YOU ARE CONSIDERING AND / OR YOUR CAREERS GOALS] MY FAVORITE MUSICAL ARTIST(S) IS / ARE…BECAUSE… UCSD Summer Summit 2009 Student-Initiated Access Programs & Services (SIAPS) a component of S.P.A.C.E.S. Phone: 858-534-7330 | Fax: 858-534-7204 | E-mail: siaps@ucsd.edu 9500 Gilman Dr. #0062 La Jolla, CA 92093-0062
  • 3. UCSD SIAPS SUMMER SUMMIT APPLICATION – PAGE 3 FULL NAME – LAST FIRST MIDDLE INITIAL I AM ABLE TO EXPRESS MYSELF BEST THROUGH… ONE THING ABOUT ME THAT PEOPLE DO NOT KNOW FROM JUST LOOKING AT ME IS… AT MY SCHOOL, ONE OF THE THINGS I AM VERY HAPPY ABOUT / GRATEFUL FOR IS… MY LARGEST STRUGGLE DURING THIS PAST ACADEMIC YEAR HAS BEEN… UCSD Summer Summit 2009 Student-Initiated Access Programs & Services (SIAPS) a component of S.P.A.C.E.S. Phone: 858-534-7330 | Fax: 858-534-7204 | E-mail: siaps@ucsd.edu 9500 Gilman Dr. #0062 La Jolla, CA 92093-0062
  • 4. UCSD SIAPS SUMMER SUMMIT APPLICATION – PAGE 4 FULL NAME – LAST FIRST MIDDLE INITIAL ACADEMIC INFORMATION SOME OF OUR WORKSHOPS WILL INCLUDE REVIEWING YOUR U.C. ELIGIBILITY BY EXPLAINING THE A-G REQUIREMENTS. PLEASE PROVIDE THE FOLLOWING INFORMATION TO ALLOW US TO BETTER SERVE YOU. PLEASE NOTE: APPLICATIONS ARE NOT DETERMINED BASED ON GRADES. / / GRADE POINT AVERAGE SCORES: ACT / SAT / PSAT PLEASE LIST ALL THE COURSES YOU HAVE TAKEN: NAME OF COURSE AND ACADEMIC TERM (FALL/SPRING) OR ATTACH A COPY OF YOUR TRANSCRIPT FRESHMAN YEAR SOPHOMORE YEAR JUNIOR YEAR UCSD Summer Summit 2009 Student-Initiated Access Programs & Services (SIAPS) a component of S.P.A.C.E.S. Phone: 858-534-7330 | Fax: 858-534-7204 | E-mail: siaps@ucsd.edu 9500 Gilman Dr. #0062 La Jolla, CA 92093-0062
  • 5. UCSD SIAPS SUMMER SUMMIT APPLICATION – PAGE 5 FULL NAME – LAST FIRST MIDDLE INITIAL WHAT ISSUES WOULD YOU LIKE US TO ADDRESS? (PLEASE CHECK ALL THAT APPLY) I WOULD BE INTERESTED IN ATTENDING WORKSHOPS & GETTING MORE INFORMATION ON…  U.C. ADMISSIONS PROCESS  TRANSFER PROGRAMS (FROM 2 YEAR COMMUNITY COLLEGES TO U.C.)  FINANCIAL AID  CAREER GOALS  RELATIONSHIPS WITH FRIENDS  RELATIONSHIPS WITH FAMILY  STEREOTYPES  MY CULTURE / HERITAGE  FAITH / SPIRITUALITY / RELIGION  LGBT (LESBIAN, GAY, BISEXUAL, TRANSGENDER/TRANSSEXUAL) / QUEER / “DOWNE” ISSUES  GENDER ISSUES  SOCIAL JUSTICE RE-CREATIONAL WORKSHOPS – RECREATIONAL WORK THAT ALLOWS US TO [RE]CREATE COMMUNITY AND OURSELVES  CREATING ZINES / YOUR OWN MEDIA  CULTURAL DANCES AND PERFORMANCES  HIP HOP  MURAL ART / AEROSOL ART  MUSIC  SPOKEN WORD / POETRY  SPORTS  WRITING PLEASE LIST ANY OTHER SUGGESTIONS THAT YOU HAVE FOR THE PROGRAM: T-SHIRT SIZE  CHILD LARGE  ADULT SMALL  MEDIUM  LARGE  X-LARGE  XXL UCSD Summer Summit 2009 Student-Initiated Access Programs & Services (SIAPS) a component of S.P.A.C.E.S. Phone: 858-534-7330 | Fax: 858-534-7204 | E-mail: siaps@ucsd.edu 9500 Gilman Dr. #0062 La Jolla, CA 92093-0062
  • 6. UCSD SIAPS SUMMER SUMMIT APPLICATION – PAGE 6 FULL NAME – LAST FIRST MIDDLE INITIAL PARENTAL PERMISSION/REGISTRATION FORM  ANY PHYSICAL CHALLENGES THAT MAY REQUIRE SPECIAL ASSISTANCE?  YES  NO IF YES, PLEASE DESCRIBE: ________________________________________________________________________  ANY MEDICATION ALLERGIES (I.E., PENICILLIN, ASPIRIN, ETC.) OR OTHER ALLERGIES (LATEX, INSECT STINGS)?  YES  NO IF YES, PLEASE SPECIFY: ____________________________________________________________________________  IS THE STUDENT BEING TREATED FOR ANY MEDICAL CONDITION (I.E., ASTHMA, DIABETES, EPILEPSY, ETC.)?  YES  NO IF YES, PLEASE SPECIFY: ____________________________________________________________________________  IS THE STUDENT COVERED BY MEDICAL INSURANCE?  YES  NO IF YES, PLEASE SPECIFY: ____________________________________________________________________________ I authorize my daughter/son to participate in the UCSD Summer Summit Program from August 21-23, 2009. In case of emergency, please contact the person listed below. I understand that unless there is an emergency situation, my health insurance carrier will be used whenever possible for my son/daughter’s medical needs. In the event of an accident or illness, I authorize UCSD staff to take steps to provide first aid to my daughter/son. The expectation by UCSD is that all students visiting the campus for this program must remain on campus with their residential advisor (RA). I have discussed this with my son/daughter and understand that UCSD is an open campus; I recognize that should my son/daughter choose to leave campus, I will not hold UC San Diego responsible. ________________________________________ _____________________________ _______________ Parent / Guardian Full Name (please print) Parent/Guardian Signature Date IN CASE OF EMERGENCY, PLEASE CONTACT: ________________________________________ _______________________________ Name Relationship to Student ________________________________________ _______________________________ Street Address City/State/Zip (_____) _______________ (_____) _______________ (_____) _______________ Day Time Phone Evening Phone Cell Phone UCSD Summer Summit 2009 Student-Initiated Access Programs & Services (SIAPS) a component of S.P.A.C.E.S. Phone: 858-534-7330 | Fax: 858-534-7204 | E-mail: siaps@ucsd.edu 9500 Gilman Dr. #0062 La Jolla, CA 92093-0062
  • 7. Participant's name: ___________________________________________ Please Print UNIVERSITY OF CALIFORNIA, SAN DIEGO Student Promoted Access Center for Education and Service (SPACES) Waiver of Liability, Assumption of Risk, and Indemnity Agreement Waiver: In consideration of being permitted to participate in any way in Summer Summit (August 21-23, 2009) hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue The Regents of the University of California, its officers, employees, and agents from liability from any and all claims including the negligence of The Regents of the University of California, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in The Activity. ________________________________________ ________________________________ Signature of Parent/Guardian of Minor Date Signature of Participant Date Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death. I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the University of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred. Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. _______________________________________ ____________________________________ Signature of Parent/Guardian of Minor Date Signature of Participant Date Vol Waiver 7/01 Participant's Age (if minor) _____