Adelina Gomez Scholars

Transcripción

1 Adelina Gomez Scholars 2016 Program Application Applications submitted by April 13, 2016 will be given first consideration. Name: School: Please make sure that your packet contains ALL of the following: Completed and signed Application Form (both student and parent must sign this form on page 3) Completed Medical Form (pages 5 & 6, sign page 6) Completed Medical Permission form (sign page 6 or 9) Completed Waiver form (sign page 8 or 11) ONE Recommendation from Teacher, Counselor or Administrator (page 12) Student Essay (prompt on page 13, please attach typed essay) Completed liability form for The Nature Place (page 14 and 15) Attached current unofficial transcript. Completed UCCS Transcript Consent Release (page 16). Agreement to attend the entire summer institute from June 8, 2016 to June 19, 2016 in Colorado Springs. Return your completed application to your school counselor or principal For questions contact: The Office of Inclusion and Academic Engagement Phone: (719) diversity@uccs.edu

2 Adelina Gomez Scholars 2016 Application page 2 School Student Information Last Name First Name Middle Initial When do you expect to graduate from high school? Mailing Address City State Zip Code Home Phone Work Phone Cell Phone Date of Birth Mother or Guardian Name Father or Guardian Name Mailing Address if different from student s Student s T-shirt Size Parent/Guardian Information Home Phone Cell Phone Mother/Guardian Phone Father/Guardian Phone Mother/Guardian Father/Guardian Mother/Guardian Father/Guardian

3 Adelina Gomez Scholars 2016 Application page 3 Grade Point Average for current year Name of School Counselor Student Information Phone What are your best subjects in school: Subjects that are hardest for you in school: Extracurricular activities and interests Are you eligible for free/reduced lunch? Are you currently employed? If yes, please name your employer How many hours do you work per week? Plans for college Will you be a first generation college student? (You are a first generation student if neither of your parents completed college) Academic & Career Interests

4 Adelina Gomez Scholars 2016 Application page 4 Student Information Are you applying to or have you been accepted to another college preparation or concurrent enrollment program for Summer 2015? If yes, please name the program. By signing below, I certify that the above information is true to the best of my knowledge and I am giving permission for UCCS to collect addition academic information about this student from their school as needed: Student Signature & date Parent/Guardian Signature & date

5 Adelina Gomez Scholars 2016 Application page 5 Emergency Contacts and Persons Authorized to Pick up Participants Mother or Guardian Name Father or Guardian Name Mailing Address if different from student s Home Phone Cell Phone Mother/Guardian Phone Father/Guardian Phone Other emergency contact/name Home Phone Cell Phone Other emergency contact/phone

6 Adelina Gomez Scholars 2016 Application page 6 Family Physician Physician s Phone Student s Medical Information (section 1 of 2) Allergies Insect bites/stings: Drugs: Food: Other: Is student under ongoing care of provider for either medical or psychological reasons? If yes, please explain. Is participant taking medically prescribed medications? If yes, please explain. Does student have physical or mental impairment? If yes, please describe. Does student have visual impairment (glasses)? If yes, please describe. Has student had a major illness in the past five years? If yes, please describe. Does student have any dietary restrictions? If yes, please describe Other information that we should know Please list any Medical Insurance Coverage Name of Insured Do you have a hospital/clinic card? If yes, please describe

7 Adelina Gomez Scholars 2016 Application page 7 Student s Medical Information, Continued (Section 2 of 2) Medicaid or Medicare Number, if you have one. By signing below, I certify that the above emergency and medical information is true to the best of my knowledge: Student Signature & date Parent/Guardian Signature & date

8 Adelina Gomez Scholars 2016 Application page 8 Adelina Gomez Scholars Program IN LOCO PARENTIS (si prefiere español, página 9) Permission is hereby given for staff members of the Adelina Gomez Scholars Program to act as my representative in signing for any medical services needed by my daughter/son: Student Name (please print) I understand that every effort will be made to ensure the safety and good health of participants in the Adelina Gomez Scholars Program. Should an accident occur, I will, in no way, hold the Adelina Gomez Scholars Program, the University of Colorado Colorado Springs, or their staff members responsible or legally liable. Parent/Guardian Name (please print) Parent/Guardian Signature Date

9 Adelina Gomez Scholars 2016 Application page 9 Informed Consent, Permission, Release and Assumption of Risk for Adelina Gomez Scholars Participants (si prefiere español, página 10) Participant Name Adelina Gomez Scholars Institute from June 8 through June 19, Participant wishes to participate in the Adelina Gomez Scholars Summer Institute ( Activity ). Participant understands that risks and dangers in the Activity include but are not limited to falls, falling objects and broken or improperly used equipment, which could result in damage to or loss of property, drowning, illness or disease, physical or mental injury or death of participant or other persons. Injuries that may result from participation in this activity may include, but are not limited to, cuts, bruises, or sprained joints, broken bones, psychological trauma, infection, and death. Participant freely participates in the Activity. Participant understands and assumes all associated risks of personal injury or loss, bodily injury (including death), damage to, loss, or destruction of any personal property occurring in connection with or arising out of participation in the Activity. 2. Participant states to the best of his or her knowledge that Participant is free from any known health condition that could hinder or prevent active participation in or otherwise jeopardize the well being of others in the Activity. By his/her signature below, Participant affirms that Participant is in good health and that participation in the camp will in no way aggravate such health condition. Participant will seek medical advice as appropriate. 3. Participant agrees to, and understands the importance of, following rules and regulations as set forth by camp leaders to minimize risk to Participant and others. Participant will neither bring nor possess any items, such as knives, weapons, and illegal drugs, or other items, which might endanger Participant or others. Possessing the above may result in removal from the Activity. 4. Participants in University of Colorado events are sometimes photographed and videotaped for use in promotional and education materials. Participant understands that such audio, video, film and/or print images may be edited, duplicated, distributed, reproduced, broadcast, and/or reformatted any form and manner without payment of fees. Participant authorizes the University of Colorado to record and photograph Participant s image for use by the University of Colorado and/or Denver Public Schools or their assignees in research, educational and promotional programs. 5. Participant hereby releases and discharges, indemnifies and holds harmless The Regents of the University of Colorado, a body corporate, and its member officers, agents, employees and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the aforementioned persons and entities, against all claims, demands, costs and expenses, and causes of action whatsoever, either in law or equity, arising out of or in any way connected with any loss and/or

10 Adelina Gomez Scholars 2016 Application page 10 bodily injury and/or disability, arising from Participant s participation in the Activity. Having had sufficient time to review and seek explanation of the provisions contained above, Participant voluntarily gives consent and agrees to this Informed Consent, Permission, Release and Assumption of Risk. This two-page document is not valid if either page is missing. Participant s Name (please print) Participant s Signature date Parent or Legal Guardian Name (please print) Parent or Legal Guardian Signature date

11 Adelina Gomez Scholars 2016 Application page 11 Adelina Gomez Scholars Program IN LOCO PARENTIS (En lugar de los Padres) Doy permiso a los empleados del Programa Adelina Gomez Scholars de la Universidad de Colorado Springs para actuar como mi representante para autorizar servicos médicos para mi hija/o durante su participación en este programa. Nombre del Estudiante (por favor, escribe con letra clara) Entiendo que el Programa Adelina Gomez Scholars hará todo lo posible para asegurar la salud y seguridad de cada participante. Si ocurre cualquier accidente, declaro que no rendiré legalmente responsable al Programa Adelina Gomez Scholars ni a la Universidad de Colorado Colorado Springs. Nombre del Padre o Tutor Legal (por favor, escribe con letra de molde) Firma del Padre o Tutor Legal Fecha

12 Adelina Gomez Scholars 2016 Application page 12 Liberación de Responsabilidades, Asunción de Riesgos y la Renuncia de Derechos para Participantes en el Programa Adelina Gomez Scholars Nombre del Participante Adelina Gomez Scholars, Instituto del Verano ( Actividad ), 10 de Junio a 21 de Junio, Yo ejerzo mi libre elección de participar en la actividad arriba designada. Yo estoy de acuerdo, entiendo y asumo todos los riesgos de daños personales y pérdidas, daños corporales tales como pero no limitados a caídas, la caída de objetos, equipo roto o usado incorrectamente, que puede resultar en daños o pérdida de propiedad, enfermedad, lesiones físicas o mentales, o la muerte del participante o de otras personas. Lesiones que pueden resultar de participar en esta actividad incluyen, pero no están limitadas, a cortadas, moretones, desgarres, fracturas, trauma psicológica, infecciones y muerte. Yo participo de propia voluntad en esta actividad. Entiendo y asumo todos los riesgos asociados con el daño y pérdida personales incluyendo muerte que puedan ocurrir asociados con la participación en el Programa Adelina Gomez Scholars. 2. Yo declaro que no tengo condiciones médicos que pueden interferir con mi participación activia o comprometer el bien estar de otros participantes. Afirmo que mí participación no comprometerá cualquier condición médica y que buscaré consejo médico si tengo dudas. 3. Me comprometo a seguir las reglas y regulaciones establecidas por las autoridades del Programa Adelina Gomez Scholars para minimizar riesgo a los participantes. No tendré en mi posesión ninginas armas, cuchillos, drogas o otras cosas peligrosas que puedan arriesgar a otros participantes. La posesión de cualquiera de estos pueden resultar en expulsión de este programa. 4. Participantes en este programa pueden ser fotografiados o videografiados para el uso de la universidad en sus programas de promoción y educación. Yo entiendo que dichas grabaciones y imágenes pueden ser editados, duplicados, distribuidos, reproducidos, transmitidos, o reformateados en cualquier formato sin compensación. Autorizo a la Universidad de Colorado en Colorado Springs a grabar, fotografiar, y filmar mi participación para el uso de la Universidad de Colorado en Colorado Springs para sus programas de promoción, educación y investigación académica. 5. Yo, por la presente libero y remuevo, indemnizo y exonero de las obligaciones a los Regentes de la Universidad de Colorado y a sus miembros oficiales, agentes, empleados u otras personas o entidades que actúen en su nombre, y a los sucesores y designados a cualquiera y todas las personas mencionadas y entidades, contra cualquier tipo de reclamos, demandas, costos y gastos, y las causas por cualquier acción, ya sea por la ley o equidad, que surjan de cualquier pérdida y/o daño y/o incapacidad, que surja de mi participación en la actividad.

13 Adelina Gomez Scholars 2016 Application page Yo he tenido suficiente tiempo para revisar y buscar explicación sobre las disposiciones contenidas arriba, las he leído muy cuidadosamente, las entiendo completamente, y estoy de acuerdo con las obligaciones requeridas. Después de una cuidadosa deliberación, yo, voluntariamente, doy mi consentimiento y estoy de acuerdo con la Liberación de Responsabilidades, Asunción de Riesgos y la Renuncia de Derechos. Si el(la) participante es menor de 18 años de edad, el padre/representante o tutor legal en consideración con esta petición acepta los términos arriba indicados y da permiso para la participación del(la) estudiante. Nombre del Participante (por favor, escribe con letra de molde) Firma del Participante Fecha Nombre del Padre o Tutor Legal (por favor, escribe con letra de molde) Firma del Padre o Tutor Legal Fecha

14 Adelina Gomez Scholars 2016 Application page 14 Student Name Student s School Recommender Name/Title Recommender Phone & How long have you known student & in what context? Teacher, Counselor or Administrator Recommendation How would you describe the student s ability to take intellectual risks and go beyond the normal classroom experience? Why would you recommend this student for the Adelina Gomez Scholars program at UCCS? Is there anything else you think we should know about this student? (feel free to use reverse side) Signature and date

15 Adelina Gomez Scholars 2016 Application page 15 Essay Prompt In 250 words or less, Describe the world you come from for example your community, family, and the obstacles you ve encountered how has your story shaped your educational goals and what have you done to overcome any obstacles you ve encountered? In addition, please explain what you would gain by participating in the Adelina Gomez Scholars Program and what specific qualities that you would contribute to this learning community. Attach your typewritten responses to your application.

16 Adelina Gomez Scholars 2016 Application page 16 Outdoor Leadership Experience at The Nature Place The Adelina Gomez Scholars Summer Institute will include an overnight stay and outdoor leadership experience at The Nature Place in Florissant, Colorado ( Please read the following and sign the liability waiver on the following page. The Nature Place Program will include programmed sessions that will focus on group problem-solving tasks. These activities do not require participants to be in excellent physical shape but may require some moderate twisting motions, lifting, and balance. Participants for whom such motions or exercise are a concern, are strongly encouraged to consult their physician before taking part in such activities. Participation in any of the above activities is at all times completely up to the individual's choice with the knowledge that there is always a risk that he or she may suffer an injury. RELEASE OF LIABILITY I understand that parts of the above mentioned activities may be physically demanding. I affirm that I do not have any medical or physical limitations and that I am not under a physician's care that, disclosed or undisclosed, might endanger my health or that of other participants. I understand that The Nature Place Program does not offer any medical insurance to protect against risk or injury, makes no claims to do so, and has no responsibility for any medical expenses I incur. I agree to assume such risks and any financial responsibility. I release The Nature Place Program, it's staff members, and Board of Directors from all liability for any injury to me from participation in the above activities. PHOTO RELEASE The Nature Place and may photograph people and activities during your stay for promotional purposes. If you object to the use of your photo, please check this box By signing the page below you accept the above conditions.

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18 Adelina Gomez Scholars 2016 Application page 18!!!!!! Adelina Gomez Scholars Program Consent for Release of UCCS Transcript I hereby authorize the Adelina Gomez Scholars program of the University of Colorado Colorado Springs, to obtain and make copies of the UCCS transcript for: Student s Name: School: Grade Level: The purpose of the Adelina Gomez Scholars Program is to help students gain admission and enroll in an institution of higher education. Transcripts will be collected by the Adelina Gomez Scholars program to assure that students are given full credit for the academic credits earned in the program. The transcripts may be transferred to the Denver Public Schools to facilitate credit transfer. Signature of Parent(s) or Legal Guardian(s): Printed Name of Parent(s) or Legal Guardian(s): Date: