Summersummitapp

UCSD Summer Summit 2009 Student-Initiated Access Programs & Services (SIAPS) a component of S.P.A.C.E.S.

Phone: 858-534-7330 | Fax: 858-534-7204 | E-mail: [email protected] 9500 Gilman Dr. #0062 La Jolla, CA 92093-0062

University of California, San Diego Student-Initiated Access Programs and Services

SIAPS SUMMER SUMMIT 2009 August 21-23, 2009

APPLICATION

Please submit the entire application by Friday, July 31st, 2009

All applications will be considered, but priority will be given to those received by the deadline.

FULL NAME – LAST FIRST MIDDLE INITIAL NICKNAME

ADDRESS CITY, STATE, ZIP CODE

PHONE NUMBER(S) DATE OF BIRTH

EMAIL GENDER ETHNICITY / RACE

HIGH SCHOOL GRADE CITY DISTRICT

VOLUNTEER EXPERIENCE / EXTRA-CURRICULAR ACTIVITIES - PLEASE LIST ACTIVITIES (ORGANIZATION(S) AND OTHER) AND BRIEFLY DESCRIBE YOUR INVOLVEMENT

WORK EXPERIENCE

FAX TO: (858)534-7204 ATTENTION: SUMMER SUMMIT PROGRAM

mailto:[email protected]

UCSD SIAPS SUMMER SUMMIT APPLICATION – PAGE 2

FULL NAME – LAST FIRST MIDDLE INITIAL



PLEASE CHECK ALL THAT APPLY: I HAVE PARTICIPATED IN A PRE-COLLEGIATE PROGRAM: AVID CAL-SOAP EARLY ACADEMIC OUTREACH PROGRAM (EAOP)

TRIO / TALENT SEARCH UPWARD BOUND OTHER: ___________________

MY TUTOR/MENTOR IS: I HAVE ATTENDED/PARTICIPATED A UCSD HIGH SCHOOL CONFERENCE / OUTREACH PROGRAM SPONSORED BY UCSD: APSA (ASIAN & PACIFIC-ISLANDER STUDENT ALLIANCE) BSU (BLACK STUDENT UNION KP (KAIBIGANG PILIPINO) MECHA (MOVIMIENTO ESTUDIANTIL CHICANA Y CHICANO DE AZTLAN) MUSLIM STUDENT ASSOCIATION (MSA) QPOC (QUEER PEOPLE OF COLOR) VSA (VIETNAMESE STUDENT ASSOCIATON)

API LEADERSHIP RETREAT CAL-SOAP COMIENZA CON UN SUENO DARE TO DREAM AN EVENING WITH UC SAN DIEGO TRIO UPWARD BOUND OTHERS: __________________________

WOULD YOU BE INTERESTED IN ATTENDING A UCSD HIGH SCHOOL CONFERENCE DURING THE COMING SCHOOL YEAR? YES NO

IF SO, WHICH ONE(S)?

AFTER HIGH SCHOOL, I PLAN TO… [PLEASE NAME THE COLLEGES/UNIVERSITIES YOU ARE CONSIDERING AND / OR YOUR CAREERS GOALS]

MY FAVORITE MUSICAL ARTIST(S) IS / ARE…BECAUSE…






I AM ABLE TO EXPRESS MYSELF BEST THROUGH…

ONE THING ABOUT ME THAT PEOPLE DO NOT KNOW FROM JUST LOOKING AT ME IS…

AT MY SCHOOL, ONE OF THE THINGS I AM VERY HAPPY ABOUT / GRATEFUL FOR IS…

MY LARGEST STRUGGLE DURING THIS PAST ACADEMIC YEAR HAS BEEN…






ACADEMIC INFORMATION SOME OF OUR WORKSHOPS WILL INCLUDE REVIEWING YOUR U.C. ELIGIBILITY BY EXPLAINING THE A-G REQUIREMENTS. PLEASE

PROVIDE THE FOLLOWING INFORMATION TO ALLOW US TO BETTER SERVE YOU. PLEASE NOTE: APPLICATIONS ARE NOT DETERMINED BASED ON GRADES. / /

GRADE POINT AVERAGE SCORES: ACT / SAT / PSAT PLEASE LIST ALL THE COURSES YOU HAVE TAKEN: NAME OF COURSE AND ACADEMIC TERM (FALL/SPRING) OR ATTACH A COPY OF YOUR TRANSCRIPT FRESHMAN YEAR SOPHOMORE YEAR JUNIOR YEAR






WHAT ISSUES WOULD YOU LIKE US TO ADDRESS? (PLEASE CHECK ALL THAT APPLY) I WOULD BE INTERESTED IN ATTENDING WORKSHOPS & GETTING MORE INFORMATION ON… U.C. ADMISSIONS PROCESS TRANSFER PROGRAMS (FROM 2 YEAR COMMUNITY COLLEGES TO U.C.) FINANCIAL AID CAREER GOALS RELATIONSHIPS WITH FRIENDS RELATIONSHIPS WITH FAMILY STEREOTYPES MY CULTURE / HERITAGE FAITH / SPIRITUALITY / RELIGION LGBT (LESBIAN, GAY, BISEXUAL, TRANSGENDER/TRANSSEXUAL) / QUEER / “DOWNE” ISSUES GENDER ISSUES SOCIAL JUSTICE RE-CREATIONAL WORKSHOPS – RECREATIONAL WORK THAT ALLOWS US TO [RE]CREATE COMMUNITY AND OURSELVES CREATING ZINES / YOUR OWN MEDIA CULTURAL DANCES AND PERFORMANCES HIP HOP MURAL ART / AEROSOL ART MUSIC SPOKEN WORD / POETRY SPORTS WRITING PLEASE LIST ANY OTHER SUGGESTIONS THAT YOU HAVE FOR THE PROGRAM:

T-SHIRT SIZE CHILD LARGE ADULT SMALL MEDIUM LARGE X-LARGE XXL






PARENTAL PERMISSION/REGISTRATION FORM

ANY PHYSICAL CHALLENGES THAT MAY REQUIRE SPECIAL ASSISTANCE? YES NO

IF YES, PLEASE DESCRIBE: ________________________________________________________________________

ANY MEDICATION ALLERGIES (I.E., PENICILLIN, ASPIRIN, ETC.) OR OTHER ALLERGIES (LATEX, INSECT STINGS)? YES NO

IF YES, PLEASE SPECIFY: ____________________________________________________________________________

IS THE STUDENT BEING TREATED FOR ANY MEDICAL CONDITION (I.E., ASTHMA, DIABETES, EPILEPSY, ETC.)? YES NO


IS THE STUDENT COVERED BY MEDICAL INSURANCE? YES NO


I authorize my daughter/son to participate in the UCSD Summer Summit Program from August 21-23, 2009. In case of emergency, please contact the person listed below. I understand that unless there is an emergency situation, my health insurance carrier will be used whenever possible for my son/daughter’s medical needs. In the event of an accident or illness, I authorize UCSD staff to take steps to provide first aid to my daughter/son.

The expectation by UCSD is that all students visiting the campus for this program must remain on campus with their residential advisor (RA). I have discussed this with my son/daughter and understand that UCSD is an open campus; I recognize that should my son/daughter choose to leave campus, I will not hold UC San Diego responsible.

________________________________________ _____________________________ _______________

Parent / Guardian Full Name (please print) Parent/Guardian Signature Date

IN CASE OF EMERGENCY, PLEASE CONTACT: ________________________________________ _______________________________ Name Relationship to Student

________________________________________ _______________________________ Street Address City/State/Zip

(_____) _______________ (_____) _______________ (_____) _______________ Day Time Phone Evening Phone Cell Phone


Participant's name: ___________________________________________Please Print

UNIVERSITY OF CALIFORNIA,

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In consideration of being permitted to participate in any way in

hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do herebyrelease, waive, discharge, and covenant not to sue The Regents of the University of California, itsofficers, employees, and agents from liability from any and all claims including the negligence ofThe Regents of the University of California, its officers, employees and agents, resulting inpersonal injury, accidents or illnesses (including death), and property loss arising from, but not limitedto, participation in The Activity.

________________________________________ ________________________________Signature of Parent/Guardian of Minor Date Signature of Participant Date

Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot beeliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity toanother, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) majorinjuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3)catastrophic injuries including paralysis and death.

I have read the previous paragraphs and I know, understand, and appreciate these andother risks that are inherent in The Activity. I hereby assert that my participation is voluntary andthat I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents ofthe University of California HARMLESS from any and all claims, actions, suits, procedures, costs,expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement inThe Activity and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption ofrisks agreement is intended to be as broad and inclusive as is permitted by the law of the State ofCalifornia and that if any portion thereof is held invalid, it is agreed that the balance shall,notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, andindemnity agreement, fully understand its terms, and understand that I am giving up substantialrights, including my right to sue. I acknowledge that I am signing the agreement freely andvoluntarily, and intend by my signature to be a complete and unconditional release of all liabilityto the greatest extent allowed by law.

_______________________________________ ____________________________________Signature of Parent/Guardian of Minor Date Signature of Participant Date

Vol Waiver 7/01

Education

Summersummitapp