For more information, please contact Shae Eason, College Outreach Advisor at: or

Transcription

1 Overview: Summer Summit Leadership Institute 2013 On behalf of Student 2 Student Outreach, we would like to extend an invitation to apply for the Summer Summit Leadership Institute (SSLI) at Weber State University. Through the support of college undergraduates, faculty and staff mentors, the SSLI will focus on providing a leadership and college preparation experience to 50 underrepresented rising high school seniors to equip them with the necessary tools to succeed in higher education. The SSLI experience will give participants the opportunity to demonstrate their skill development in the areas of leadership, cultural diversity, civic engagement and college preparation, as well as a STEM (Science, Technology, Engineering and Math) academic group project. Additionally, if selected, participants will receive housing, meals, course materials, supplies and on-campus transportation at no cost. Eligibility The Summer Summit Leadership Institute is a four-day summer residential program. To be eligible to apply, students must: Be enrolling in the 12 th grade for Fall 2013 at a public or private high school in Utah Have a minimum GPA of 2.5 on a 4.0 scale Be an underrepresented student (defined as ethnically-diverse, first in their family to attend college, or on a free or reduced lunch program) Have a desire to go to college after completing high school Instructions: a completed application packet must include the following: A completed application form Student Release form One letter of recommendation from a teacher or high school counselor (Please see instructions for recommendation letter page) An official transcript from your current high school A one page typed statement answering the following questions: 1. Describe why you want to participate in the WSU Summer Summit Leadership Institute. 2. This program requires students to work towards developing the following traits: responsibility, working as a team player, working independently, gaining good listening skills, a willingness to learn, and a desire to go to college. Choose two traits from the list above and describe ways you currently display them in your life. Submit your UNSTAPLED application to your school counselor and/or college representative or mail it to: Student 2 Student Outreach 1122 University Circle, Suite 150 Weber State University Ogden, UT For more information, please contact Shae Eason, College Outreach Advisor at: or S2S@weber.edu

2 Please return this application filled out and signed. If selected, an acceptance packet will be sent to you about two weeks prior to Summit which will provide an agenda, and other information. For questions, please contact Student 2 Student Outreach at (801) Name Address City State Zip Home Phone Student Cell Phone Student Gender ( ) Male ( ) Female High School Year in School G.P.A. Did any of your parents graduate from a 4-year college or University? Yes No Name of the institution: Degree obtained: (Please check one) Ethnic Origin: Black/African American Asian Latino/Hispanic/Chicano Caucasian Native American or Alaskan Native Pacific Islander Emergency Contact: Relationship: Phone: Size for T-Shirt (S, M, L, XL, XXL) Household Income: $1-$30,000 $30,001-$48,000 $48,001-$72,000 (Please check one) $72,001 or more How many are in your household? (Include all adults and children): After high school, do you plan to attend Weber State University? Yes NO If no, where do you plan to attend? Rank these in order of most interested (1) to least interested (5). Health Professions Technology Education Science Education Engineering The Summer Summit Leadership Institute is a four-day event and participants are expected to stay overnight at WSU. Application deadline is April 26, 2013 Student/Applicant Signature: Date: Parent/Guardian Signature: Date:

3 Student Release Form Participant s name: Parent/Guardian s name: Read and initial each item below. I give Student 2 Student (S2S)/ Weber State University (WSU) permission for any pictures or video taken of my student during the program to be used in future promotional materials for S2S/WSU. Yes No (Please initial) I give permission for my student to travel on approved educational field trips with S2S/WSU staff. Yes No (Please initial) I give permission for my student s information to be referred over to other campus departments for potential enrollment into the university. Yes No (Please initial) I authorize WSU/S2S staff to obtain routine and/or emergency medical services (if necessary) for my student during his/her entire period in the program. Yes No (Please initial) List below any necessary medications, accommodations or other pertinent health or learning conditions my student may have The student is covered by a medical insurance plan: Yes ( ) No ( ) If yes: Name of the health plan Policy Holder Group or policy number ID Phone Number I recognize that participation in Weber State University/ Student 2 Student Summer Summit Leadership Institute may involve moderate to strenuous physical activity and may cause physical and/or emotional stress to participants. There may also be associated health risks. I state that the student is free from any known heart, respiratory or other health problems that could prevent the student from safely participating in any of the activities. Initial I certify that I have medical insurance or otherwise agree to be personally responsible for costs of any emergency or other medical care that the student receives. I agree to release State of Utah, Weber State University and their agencies, departments, officers, employees, agents, and all sponsors, officials and staff or volunteers from the cost of any medical care that the student receives as a result of participation in the camp. Initial I further agree to release the State of Utah, Weber State University/ Student 2 Student, their agencies departments, officers, employees, agents and all sponsors, staff or volunteers from any and all liability, claims, demands, breach of warranty, negligence, actions, and causes of actions whatsoever for any loss, claim, damage, injury, illness, attorney s fees or harm of any kind or nature to me arising out of student s participation in this Weber State University/ Student 2 Student Summer Summit Leadership Institute. This release extends to any claim made by the parents or guardians or their assigns arising from or in any way connected to the aforementioned activities. Initial

4 Consent Consent, is expressively given, in the event of any injury, for any emergency aid, anesthesia, and/or operation, if in the opinion of the attending physician, such treatment is necessary. Initial I have carefully read and understand the contents of the forgoing language and I specifically intend it to cover student s participation in the above stated Weber State University/ Student 2 Student Summer Summit Leadership Institute. Initial I, for myself, my heirs, successors and executors, hereby knowingly and intentionally, waive and release, indemnify and hold harmless the State of Utah, Weber State University (WSU)/ (S2S) Program and their staff, volunteers and other participants from and against all claims, actions, causes of actions, liabilities, suits and expenses arising directly or indirectly from my student participating in this program. Further, we agree not to sue the State of Utah or Weber State University, including individual employees and participants. Initial 1. I will not possess weapons, combustible materials or consume any alcohol, tobacco or illegal drugs during the camp. 2. I will not leave the location of the camp (hospital, hotel, restaurant, group activity). 3. I will not use my own vehicle during the camp without permission from the camp staff. 4. I will respect the WSU student housing and established time to be in rooms each evening. 5. I understand that all student participants must be present for all days of camp. 6. I understand that cell phones and other electronic devices must be turned off during instructional time. 7. I understand that unregistered guests are not allowed. 8. I understand that I am responsible for any damages to the dorm room that occurs beyond normal wear and tear and any need for repairs should be reported immediately. 9. I understand that I will not be able to participate in the camp if I do not comply with all the above and any other guidelines communicated by the camp staff. YES NO (Please initial) Student Signature Date Student Name (Print) Parent Signature Date Parent Name (Print) OFFICE USE: Emergency Contact: Student Initials: Student Signature: Parent/Guardian Signature: Parent/Guardian Initials:

5 Instructions for Recommendation Letter Choose a teacher or counselor from your school who is familiar with your strengths and is willing to support your application to attend Summer Summit Leadership Institute. Teacher or counselor: The Summer Summit Leadership Institute is a four-day residential college experience for underrepresented rising high school seniors (also defined as ethnically-diverse, first in their family to attend college or on free or reduced lunch programs). Summer Summit Institute will select 50 participants and provide them the opportunity to demonstrate their skill development in the areas of leadership, cultural diversity, civic engagement and college preparation, as well as a STEM (Science, Technology, Engineering and Math) academic group project. Qualified applicants must have a minimum 2.5 cumulative GPA and be a high school senior in Fall Please include the following information in your letter: Applicant s name Provide a statement describing this student s potential to be a successful participant in the Summer Summit Leadership Institute. Your name School telephone number and best time to contact you during school hours Your address Your signature *The completed application to include this letter of recommendation should be postmarked by April 26, 2013 Student 2 Student Outreach 1122 University Circle, Suite 150 Weber State University Ogden, UT *For additional questions, please contact Shae Eason, College Outreach Advisor at: or S2S@weber.edu