SHPE Outreach 2015 Application Packet

Transcripción

1 SHPE Outreach 2015 SHPE Outreach 2015 Society of Hispanic Professional Engineers Rensselear Polytechnic Institute S H PE OUTREACH RPI S t u d ent U n i on t h S t r eet T r oy, N Y

2 Table of Contents Student Application... 2 Student Information... 2 High School Information... 2 Medical Information... 2 Student Questionnaire... 3 Liability Release, Parent Permission & Emergency Contact Form... 4 English Version... 4 Spanish Version... 5 Photo Consent & Release Forms... 6 Rensselaer Video Services Standard Release... 6 SHPE Foundation Photo Consent and Release... 7 Application Submission Deadlines Please postmark all student applications by February 2nd, 2015 so that applications will arrive by the deadline of February 6th, 2015 to ensure that your application has been received you may contact us one week following your submission. All applicants will be informed if they are accepted or denied from the program by February 13, The SHPE Outreach Committee will communicate your acceptance or denial to you via phone call. Please notify us at least one week in advance if you are unable to attend the program. Where to Send Please mail all student applications to the following address: What to Send 1. Student Application 2. Student Transcript 3. Liability Release, Parent Permission, & Emergency Contact Form 4. Photo Consent & Release Form ATTN: SHPE Outreach RPI Student Union th Street Troy, NY Incomplete applications will not be considered for acceptance! 1

3 Student Application Student Information First Name Address Last Name Phone Gender Male Female City State Zip Code Age Ethnicity Hispanic African American White Asian American Indian Other Prefer Not To Specify High School Information High School SHPE Jr. (if applicable) Guidance Counselor Name Phone GPA (ie. 3/4; 95/100) Class Year Freshman Sophomore Junior Senior PLEASE ATTACH STUDENT TRANSCRIPT Medical Information Insurance Company (if no insurance please indicate with N/A) Policy/Account/Identification Number (if no insurance please indicate with N/A) Student Date of Birth Please list any known allergies Please list any medications the student is taking Please list any medical problems which require special attention Please list any important medication information about the student Please list any food preferences (ie. kosher, vegetarian, etc.) 2

4 Student Questionnaire Academic areas of interest (check all that apply) Is your primary career choice in a major outside of STEM? If so, please indicate which major. Engineering Civil Mechanical Aeronautical Chemical Biomedical Electrical/Computer Industrial Science Biology Chemistry Physics Astronomy Pre-Med/Nursing Mathematics Web/Information Technology Architecture Management Business Finance Accounting Information Systems Humanities Art Psychology Graphic Design Social Science Pre-Law What do you hope to gain from attending SHPE Outreach? Where do you hope to see yourself in 5 years? How will attending college help you reach your goals? Indicate any extracurriculars you are involved with. 3

5 Liability Release, Parent Permission & Emergency Contact Form English Version I understand that the Society of Hispanic Professional Engineers, Inc. (SHPE), SHPE Foundation and its affiliated staff will not be liable for any unauthorized leave by the above named student. I further understand that such unauthorized leave will be the responsibility of the student and the parent or the legal guardian as the signatory below. I, (insert parent/guardian name) hereby release SHPE Inc. and SHPE Foundation employees or volunteers from any and all liability for any and all harm arising to my son/daughter as a result of the field trips and/or activities, and waive any claims against them. I hereby state that I am the custodial parent or legal guardian of (insert student name), a minor. I therefore, grant permission for this Student to attend/participate in the Society of Hispanic Professional Engineers, Inc. (SHPE, Inc.), the Society of Hispanic Engineers Foundation (SHPE Foundation) or SHPE Chapter funded activities, field trips or to attend any authorized activities as part of the SHPE, Inc. or SHPE Foundation Programs. In the event of an emergency and if neither emergency contact can be reached; I, the undersigned, authorize SHPE to take any emergency medical measures deemed necessary for the care and protection of my child. This includes, if necessary, treatment by a physician, paramedic, and/or transfer to the hospital. I give permission for limited treatment for minor illness and/or injuries. In case of emergency, the student will be referred to the nearest medical facility for care at the expense of the parent or under insurance provided by the student s insurance. Students should immediately report any injury or illness symptom to the chaperone or SHPE. Failure to report such a condition would be the sole responsibility of the student, and SHPE would not be held responsible in case the situation worsens. Name Emergency Contact 1 Emergency Contact 2 Relationship to Student Primary Phone Secondary Phone Parent/Guardian Signature 4 Date

6 Spanish Version Formulario Liberación de Responsabilidad, Autorización de Tutores y Contacto de Emergencia Por la presente yo testifico ser el padre con custodia o tutor legal de (inserte el nombre del estudiante) que es menor de edad y por consiguiente le doy permiso para participar en cualquier actividad patrocinada por la Society of Hispanic Professional Engineers, Inc. (SHPE), Fundación SHPE (SHPE Foundation) or SHPE Chapter, viaje patrocinado o actividades autorizadas por SHPE o la Fundación SHPE. Entiendo que la Society of Hispanic Professional Engineers, Inc. (SHPE), Fundación SHPE (SHPE Foundation), sus afiliados voluntarios o empleados no serán responsables por la separación no autorizada del grupo, por parte del mencionado alumno. También entiendo que cualquier separación no autorizada será responsabilidad del alumno o el padre o tutor legal según firmado aquí abajo. Yo libero y declaro libre de cualquier responsabilidad, a SHPE Inc. y Fundación SHPE (SHPE Foundation), sus empleados, o voluntarios de todas y cualquier responsabilidad y daños ocasionados a my hijo/hija como resultado del viaje o actividades y me abstendré de levantar cargos en contra de ellos. En la eventualidad de una emergencia y en caso de que ninguna de las personas puedan ser contactadas; Yo, el signatario, autorizo a SHPE a tomar las decisiones médicas, relacionadas con la atención y protección necesaria para mi hijo/hija. Esto incluye, si fuese necesario, tratamiento médico, paramédico y/o visita al hospital. También doy mi permiso para tratamiento limitado de enfermedades o lesiones leves. En caso de emergencia, el estudiante será trasladado a la clínica más cercana para tratamiento a costa de los padres o proveedor de seguro médico del estudiante. En caso de lesión o enfermedad los estudiantes deberán informar al inmediatamente al chaperón o representante de SHPE. Cualquier consecuencia derivada por la falta de información de cualquier situación será responsabilidad del estudiante y no se responsabilizara a SHPE en caso que dicha condición empeore. Nombre Contacto de Emergencia 1 Contacto de Emergencia 2 Relación Primero Teléfono Secondario Teléfono Firma del padre o tutor legal 5 Fecha

7 Photo Consent & Release Forms Rensselaer Video Services Standard Release In consideration of value received, the receipt of which is hereby acknowledged, I hereby give RENSSELAER POLYTECHNIC INSTITUTE, its legal representatives and assigns, and those acting with permission of Rensselaer Polytechnic Institute or employees of Rensselaer Polytechnic Institute, the right and permission to copy write and/or use, reuse and/or broadcast and republish still photographs, motion pictures, digital media, videotapes and/or associated or independent audio recordings of me, on reproductions thereof in color, or black and white made through any media, for any purpose whatsoever, including the use of any printed matter in conjunction therewith. I hereby waive any right to inspect or approve the finished still photographs, motion pictures, digital media, videotapes and/or associated or independent audio recordings, or advertising copy or printed matter that may be used in conjunction therewith or to the eventual use that it might be applied. I hereby release, discharge and agree to save harmless Rensselaer Polytechnic Institute, its representatives, assigns, employees or any person or persons, corporation or corporations, acting under its permission or authority, or any person, persons, corporation or corporations, for whom it might be acting, including any firm publishing and/or distributing the finished product, in whole or in part, from and against any liability as a result of any distortion, blurring or alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in the taking, processing or reproduction of the finished product, its publication, distribution or broadcast. I hereby certify that I am under/over eighteen years of age and competent to contract in my own name in so far as the above is concerned. I have read the foregoing release, authorization and agreement, before affixing my signature below, and warrant that I fully understand the contents thereof. I hereby certify that I am the parent and/or guardian of, an infant under the age of eighteen years, and in consideration of value received, the receipt of which is hereby acknowledged, I hereby consent that all still photographs, motion pictures, digital media, videotapes and/or associated or independent audio recordings which have been, or are about to be made by Rensselaer Polytechnic Institute may be used for the purposes set forth in original release hereinabove, signed by the infant, with the same force and effect as if executed by me. Parent/Guardian Name Parent/Guardian Signature Address Witness Name Witness Signature 6

8 SHPE Foundation Photo Consent and Release English Version I hereby authorize Society of Hispanic Professional Engineers (SHPE) and Society of Hispanic Professional Engineer Foundation, and those acting pursuant to its authority to: a. Record my likeness and/or voice on a video, audio, photographic, digital, electronic or any other medium; b. Use my name in connection with these recordings; c. Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, Internet/WWW) these recordings for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. I release the SHPE and SHPE Foundation and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of the SHPE and SHPE Foundation. I have read and fully understand the terms of this release. Student Name Address Phone Student Signature Parent/Guardian Signature Date Spanish Version Consentimiento Fotográfico y Forma de Prensa Autorizo a la Sociedad Hispana de Ingenieros Profesionales (SHPE) y la Fundación de la Sociedad Hispana de Ingenieros Profesionales (Fundación SHPE), y aquellos que actúan conforme a su autoridad para: a. Filmar, grabar mi imagen y/o voz en un video, medios audio, fotografía, digital, electrónico o cualquier otro; b. Utilizar mi nombre en relación con esas grabaciones; c. Para utilizar, reproducir, exhibir o distribuir en cualquier medio de comunicación (por ejemplo, publicaciones impresas, cintas de vídeo, CD-ROM, Internet/WWW) estas grabaciones para cualquier propósito de la Universidad y conforme a lo que se considere apropiado, incluyendo promocionales o publicidad. Absuelvo a SHPE y la Fundación SHPE y a todos aquellos actuando bajo su autoridad, de toda responsabilidad por cualquier violación del derecho a la privacidad o personal que pudiera tener con dicho uso. Comprendo que todas las grabaciones, en cualquier medio, seguirán siendo propiedad de SHPE y la Fundación SHPE. He leído y comprendido los términos de este comunicado. Firma del padre o tutor legal Fecha 7