Syracuse Delegation PRHYLI Application click here for website with required forms

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Eduardo Calderón Franco
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1 Instructions: Syracuse Delegation PRHYLI Application click here for website with required forms 1. Fill out application form on-line and print it out or - print it out and fill it in by hand. Verify that , emergency, cell and home phone numbers are correct. Application must be postmarked by December 11, Mandatory attendance is required for all five (5) trainings: Friday, January 15; Saturday February 13; Friday, February 26; Friday, March 4; and a date in March TBD. Weekend in Albany, Saturday March 19 Monday March 21, Principal s Signature on 3 forms: a. Application Form b. Excused Absences Form c. Student Conduct Contract 3. Guidance Counselor s Signature on a. Application Form 4. Parent(s) Signature on: a. Excused Absences Form b. Photo Release Form c. Parental/Medical Consent Form d. Student Conduct Contract 5. Typed Essay in Spanish or English a. Format: Times Roman or Arial 12 font, 1 margins, double-spaced b. Recommendation Forms: a. 1 st Recommendation form (given to: ). b. 2 nd Recommendation form (given to: ). c. 3 rd Optional Recommendation form (given to: ). c. Most recent transcript (check with Guidance Counselor) d. ALL application documents must be postmarked on or before December 11, 2015 Mail to: Mid-State RBERN, Attn: PRHYLI - PO Box 4774, Syracuse, NY rbern@ocmboces.org or Fax: Note: Applications sent by /fax will not be considered complete until all completed documents are received at Mid-State RBERN. Original paper copies with signatures must be received and postmarked on or before December 11, Applicants receive an or text message confirming acceptance.

Mandatory attendance is required for all five (5) trainings: Friday, January 15; Saturday February 13; Friday, February 26; Friday, March 4; and a date in March TBD.

2 Angelo Del Toro Puerto Rican/Hispanic Youth Leadership Institute Syracuse Delegation Student Application Form 2016 Personal Data Due by December 11, 2015 Name Check one: Male Female Age Address City NY, (Zip Code) Phone: (home) (cell) (emergency) Education Record High School District Address City, NY Zip Code Name of School Contact Contact s phone Contact s Check all that apply: 11th grade 12th grade I have participated previously in PR/HYLI. Course(s) you have taken, or are currently taking that align to the PR/HYLI Institute: Participation in Government Economics US History Related Electives/Please List Name(s) List any extra-curricular activities relevant to PR/HYLI: X Principal s Signature Date X Guidance Counselor s Signature Date Signature verifies school s commitment to allow student to participate in the five mandatory training sessions on Friday, January 15; Saturday February 13; Friday, February 26; Friday, March 4; and a date in March TBD AND the statewide Hispanic Youth Leadership Institute on March 19-21, 2016.

Education Record High School District Address City, NY Zip Code Name of School Contact Contact s phone Contact s email Check all that apply: 11th grade 12th grade I have participated previously in

3 2016 APPLICATION ESSAY QUESTION Format: Times Roman or Ariel 12 font, 1 margins, double spaced The Hispanic Youth Leadership Institute is named in honor of Angelo del Toro. Assemblyman del Toro captured, in his life and work, the ideals and determination that bring younger Latino/Latina leaders together in Albany each year. The Institute is a product of his vision and energy. This year s theme centers on Civic Participation and Advocacy. Angelo del Toro epitomized active civic participation and advocacy through his work in supporting children, the elderly and the poor. All can be inspired by Angelo del Toro s life as an example of what is possible for those who believe in themselves and their potential in serving their communities. Your task: Research Angelo del Toro Some links to assist with your research: Then, write a short, concise reflection not to exceed 500 words addressing the following question: Which qualities and leadership skills do you feel are necessary to enact positive change in your community?

The Institute is a product of his vision and energy. This year s theme centers on Civic Participation and Advocacy.

4 Parental Consent Form and Principal s Acknowledgement of Excused Absences (TWO SIGNATURES NEEDED A PARENT & PRINCIPAL S) Name Emergency Contact Name School Phone Phone This is to certify that we the undersigned/guardians of in consideration for the benefits to be derived by our son/daughter at the PR/HYLI, do certify that he/she may participate in any normal and routine educational or recreational programs of the PR/HYLI, hereby release and discard the NYS Education Department, Office of Bilingual Ed., Delaware Academy, Syracuse Teacher Center and OCM BOCES Mid-State RBERN, their officers, agents, instructors and employees from any and all illness, injury or accident occurred in or suffered by said son/daughter while traveling to, attendance at or participation in the PR/HYLI from the time of his/her departure from home until his/her return hereto. This will further certify that we, the undersigned parents/guardians, hereby consent and grant permission should the necessity arise, to the furnishing of medical treatment and hospital services as ordered or recommended by a qualified physician, including the administration of an anesthetic, laboratory procedures, medical or surgical treatment, x-ray examination, or other hospital services. Consent is hereby granted to the attending physician(s), hospital(s), and/or clinics to release necessary information to our local doctors and for use in claims for insurance coverage. I also understand that my child will be required to attend a series of (4) training sessions that will take place on January 15, February 13, 26 and March 4, & TBD. In addition, I understand my child, if selected, will be leaving for Albany on March 19, at 8:00 am and returning at approximately 4:00 pm on March 21. The adult chaperones will remain with him/her. I will make the necessary arrangements to be on time. Please list any medical conditions/medications/dietary needs Por este medio se certifica que los padres/guardianes de que aquí firman en consideración de los beneficios que recibirá nuestro hijo/hija en el PR/HYLI, certificamos que él/ella puede participar en cualquier rutina educativa y recreativa del programa. Por lo tanto, comprendemos que el Departamento de Educación de NYS, Oficina de Educación Bilingual, Academia de Delaware, el Centro de maestro de Syracuse, OCM BOCES Mid-State RBERN, sus oficiales, agentes, instructores, y empleados no son legalmente responsables de cualquier enfermedad o accidente causado o sufrido por mi hijo/hija mientras viaje, asista, o participe en el programa PR/HYLI desde el momento de partida hasta su regreso. Además, esto certifica que damos permiso, en caso de emergencia, para que se le administre ayuda médica o servicios clínicos según sea recomendado u ordenado por un médico acreditado, incluso la administración de anestesia, exámenes de laboratorio, tratamiento médico o quirúrgico, exámenes de rayos x, y otros servicios médicos. Se da aquí autorización al médico, hospital, y/o a la clínica para obtener y proporcionar la información médica necesaria para completar formularios de seguros. Además, comprendo que mi hijo/hija deberá asistir a una serie de 5 talleres de entrenamiento que se llevarán a cabo durante los días, 15 de enero, y 13 & 26 de febrero, y el 4 &? de marzo, de Además, entiendo que si sea selccionado(a) la partida para Albany será el sábado 19 de marzo a las 8:30 a.m. y que mi hijo/hija estará de regreso el lunes 21 de marzo de 2016 a las 4:00 p.m. aproximadamente. Los chaperones esperarán con él/ella. Haré los arreglos necesarios para estar allí a tiempo. Por favor, mencione cualquier condición física, medicamentos o necesidades dietéticas de su hijo/hija. Date/Fecha Parent s Signature/Firma del padre o de la madre: Principal s Signature: Date/Fecha

recreational programs of the PR/HYLI, hereby release and discard the NYS Education Department, Office of Bilingual Ed.

5 PHOTO, VIDEO & ESSAY RELEASE FORM We, (parent/guardian name) of (student name) hereby give OCM BOCES, New York State Education and the Puerto Rican Hispanic Task Force and their legal representatives and assigns, the right and permission to publish, without charge, photographs, videos and essays taken during the Puerto Rican Hispanic Youth Leadership Institute (PRHYLI) taking place March 29-21, 2016 and all PRHYLI training sessions: January 15, February 13 & 26, March 5 & a March date TBD, 2016 (dates subject to change). These photographs, videos and essays may be used in publication, including electronic publication, in audiovisual presentations, promotional literature, and advertising or in other similar ways. We hereby warrant that we are over eighteen (18) years of age, and are competent to contact in our names. Signature(s): Names of Above (please print) Month/Date/Year: Address: City, State, Zip: Primary contact can be reached at: Work: Home: Disclaimer: Above information is held in confidence and is never released or sold E Molloy Rd Syracuse NY (315)

2016 and all PRHYLI training sessions: January 15, February 13 & 26, March 5 & a March date TBD, 2016 (dates subject to change).

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