UCSB-Smithsonian Scholars Program Do you have an interest in conservation science and research? We offer students early field and lab experiences that connect participants to the Smithsonian Institution and UC Santa Barbara. Eligibility Santa Cruz Island, California Must be first-generation and/or low-income student, and: Smithsonian National Museum of Natural History, Washington D.C. Have completed a minimum of one year of full time credits at their host institution. Are pursuing a Science, Technology, Engineering and Mathematics (STEM) major. Have an interest in learning about conservation science research in ecology, sustainability, evolutionary genetics, human-wildlife disease, and/or reproductive physiology. An enrollment form is REQUIRED to participate in any of our activities. Deadline to enroll for internships and summer programs is January 19, 2018 (See website link below). To get involved, contact our program coordinator: Erica Johnson Erica.Johnson@ucsb.edu Office of Education Partnerships University of California, Santa Barbara http://oep.ucsb.edu/programs/smithsonian_scholars_project/ Smithsonian Mason School of Conservation lab in Front Royal, Virginia Benefits We provide workshops that expose students to field experiences, prepare students for internships and graduate school through professional development workshops, and small group seminars that highlight Smithsonian, UCSB, and affiliate research projects. Visit and learn about exciting research at the UCSB NRS station on Santa Cruz Island. Visit Smithsonian research facilities in Virginia and Washington D.C. Expand your professional and academic network while you receive valuable research training and mentoring from STEM researchers. Smithsonian Conservation Biology Institute in Front Royal, Virginia Barro Colorado Island, Panama
2017-18 UCSB-Smithsonian Scholars Program Enrollment Form Office of Education Partnerships University of California, Santa Barbara PLEASE COMPLETE ALL ITEMS First Name Middle Name Last Name Suffix (e.g. Jr.) Student Date of Birth / / mm/dd/yyyy; e.g., 01/02/1968) Gender Other Male Female College /University Major Expected year to transfer Expected 4-year college graduation year *Please mark NA for Not Applicable and UK for Unknown Home Address City State Zip code Student Cell Phone - - Student School Email Address Alternate Email Address Emergency contact name(s) First Name Middle Name Last Name Suffix (e.g. Jr.) Emergency contact Phone - - 1 Continues on other side
Father s Education Level Did not graduate from high school High School graduate Some college, but no B.A. Four-year college graduate or higher Decline to State/Don't Know Ethnicity (choose all that apply) African-American/Black American-Indian/Alaskan Native Tribe Chinese/Chinese-American East Indian/Pakistani Filipino/Filipino-American Japanese/Japanese-American Korean/Korean-American Mexican/Mexican-American/Chicano Mother s Education Level Did not graduate from high school High School graduate Some college, but no B.A. Four-year college graduate or higher Decline to State/Don't Know Pacific Islander (includes Micronesian, Polynesia other Pacific Islanders) Vietnamese/Vietnamese-American White/Caucasian Other Asian (Not including Middle Eastern) Other Spanish-American/Latino (includes Cuban, Puerto Rican, Central and South American) Other State: Decline to State/Don't Know Do you consider any of the following demographic applicable to you? 1 st generation college student Yes No Decline to State/Don't Know Underrepresented minority Yes No Decline to State/Don't Know Low-income Yes No Decline to State/Don't Know OPTIONAL for planning and logistics purposes only Do you have a valid driver s license? Yes No Decline to State/Don't Know Do you have your own means of transportation? Yes No Decline to State/Don't Know 2 Continues on other side
Do you participate or have you participated in any extracurricular activities outside of school? This includes job(s), internship(s), club(s), program(s), etc. If yes, please write a list below or attach a resume. Please continue to the FERPA Form and answer the essay prompt. 3 Continues on other side
Family Educational Rights and Privacy Act (FERPA) I give my permission for The Office of Education Partnerships to obtain information about my academic performance from schools, school districts, and colleges, to give my name and address to college and employer representatives. Student Signature: Date: For minors: I give my permission for The Office of Education Partnerships to obtain information about my child s academic performance from schools, school districts, and colleges, to give my child s name and address to college and employer representatives. Parent Signature: Date: ********************************************************************************** Please continue to the essay prompt. 4
Instructions: Please write a 1-page response to the essay prompt below or attach a separate document (Times New Roman, 12-point font, 1-inch margin, 1,000 word limit). Essay Prompt: Please share with us your past and present academic history and other experiences which you feel have prepared you for the UCSB-Smithsonian Scholars program. What do you hope to accomplish through the UCSB-Smithsonian Scholars Program? 5
University of California, Santa Barbara Release & License to Use Image, Name, and /or Voice INSTRUCTIONS Use the Release & License to Use Image, Name, and/or Voice to obtain permission from individuals to use their image or visual likeness, their name, and/or their voice in University publications or other productions. If this Release & License is being granted with respect to a minor, it is necessary to first obtain the prior consent of the minor s parent(s) or legal guardian(s). Contact UCSB Risk Management for additional information. DEPARTMENT Department: Office of Education Partnerships Class/Activity: Office of Education Partnerships UCSB-Smithsonian Scholars Program Describe the possible uses for which the Department may use the individual s image, name, and/or voice: Program publicity (newspapers, radio, television, and UCSB s webpage) RELEASE & LICENSE This Release & License is for the following Personal Information: (Initial all Personal Information for which permission to use is being given) Image/Visual likeness Name Voice? Need Help Filling out this Section? Parent/Guardian: Please write your Name s Initials for every line you approve. Write No if you do not approve. Sample: If your name (signature) is Juan Mora, your initials are J.M. J.M. J.M. J.M. Image/Visual likeness (photo) Name Voice (recording) I, the undersigned, hereby grant the Regents of the University of California ( University ) permission to use, exploit, adapt, modify, reproduce, distribute, publicly perform and display, in any form now known or later developed, my image or visual likeness, my name and/or my voice (the Personal Information ) as specified in this Release & License and indicated above, throughout the world, by incorporating it or them into publications, catalogues, brochures, books, magazines, photo exhibits, motion picture films, videotapes, and/or other media (the Works ) or commercial, informational, educational, advertising, or promotional materials relating thereto. I release, and hereby agree to indemnify, defend, and save harmless University, its agents, employees, licensees and assigns (collectively, Released Entities ) from any and all claims I, or any third party, may have now or in the future for invasion of privacy, right of publicity, copyright infringement, defamation or any other cause of action arising out of the use, exploitation, reproduction, adaptation, distribution, broadcast, performance or display of the Personal Information. I waive any right to inspect or to approve any Works that may be created using the Personal Information and waive any claim with respect to the eventual use to which the Personal Information may be applied. The Personal Information may be used at the University s sole discretion, with or without my name or with a fictitious name, and with fictitious or accurate biographical material, alone or in conjunction with any other material of any kind or nature except that University will not use the Personal Information for any criminal or illegal purposes or in a manner inconsistent with community standards of decency. I understand and agree that University is and shall be the exclusive owner of all right, title, and interest, including copyright, in the Works, and any commercial, informational, educational, advertising, or promotional materials containing the Materials. I am of full legal age and have read this release and am fully familiar with its contents. By their signature below, a minor s parent(s) or legal guardian(s) indicate, on behalf of their minor child, their full and unqualified consent to the terms of this Release & License. Name: Signature (not required if minor): Date: Age (if Minor): Name of Parent(s)/Guardian if Minor: Signature of Parent/Guardian if Minor: Address: Release & License to Use Image, Name, and/or Voice - rev. 2/05 Date: Ph: Risk Management, UC Santa Barbara http://www.riskmanagement.ucsb.edu