Kennedy King College-Minority Science and Engineering Improvement Program 2013

Transcription

1 Dear Student & Parent/Guardian: This is the Application Packet for the Minority Science and Engineering Improvement Program at Kennedy King College. All documents within this packet must be completed and signed. In addition, we ask that you take the time to write neatly and clearly. Thank you, Martin O. Pieters Print Student s Name: Forms: Completed 1. Registration Form Protocol Interview Parent Consent for Authorization for Medical Attention and Release From Liability Photo Release form... Page 1

2 Form #1 STUDENT S NAME: REGISTRATION FORM Academic Year SCHOOL: GRADE: DIV: STUDENT ID#: SEX: Male Female BIRTH DATE: STUDENT S FATHER/GUARDIAN S NAME: FATHER/GUARDIAN S MOTHER/GUARDIAN S NAME: MOTHER/GUARDIAN S FATHER/GUARDIAN S CELL PHONE #: MOTHER/GUARDIAN S CELL PHONE #: The address provided below: (Is this a change of address yes ADDRESS: no for our files?) CITY: STATE: ZIP CODE: HOME PHONE #: PARENT S WORK #: PARENTS PLACE OF EMPLOYMENT: FATHER/GUARDIAN: EMERGENCY CONTACT INFORMATION NAME: PHONE #: NAME: PHONE #: PARENT/GUARDIAN S SIGNATURE: MOTHER/GUARDIAN: COMMENTS: PARENTS, DO NOT WRITE BELOW THIS LINE SIGNATURE: DATE: Page 2

3 Form #2 PROTOCOL PRINT STUDENT S NAME: ATTENDANCE Eighty percent attendance in the Program is required of each participant this includes but is not limited to: Classes, Enrichments, and Workshops. Parents must call the main office if students will be absent. Students must call the main office if they are going to be tardy/late. Students will not be dismissed early from the Program without a telephone call and written notification from the student s parents. Parents are required to send written notification to the Program Director for students who have scheduled a planned absence for more than two consecutive days. This written notification must include the dates that students will not be in attendance. Parents are required to provide MSEIP staff written notification of any medical conditions their student may have. Students who are absent for medical reasons will not be permitted to participate in program activities without a written medical release from their physician. Students will not enter any Kennedy King College facility, including but not limited to (Coffee Shops, Bookstores, etc.) without prior permission from MSIEP staff. ATTIRE/WEAR APPAREL We strongly encourage students not to carry large sums of money, wear expensive jewelry or carry electronic equipment that will attract unwarranted attention, especially if they are traveling by public transportation to and from the campus. It is important that students dress appropriately for MSEIP classes and activities. Classrooms are air conditioned during the summer and may be cool in the winter months because of the proximity of classrooms to entryways. Students should layer their clothes so that they can add or remove items as needed to accommodate temperature changes. The wearing of hats, caps and other head coverings in doors is not permitted, except for students who wear caps or other head coverings because of their religious beliefs or for medical or health reasons. Pants must be worn at a level that will not expose the student s undergarments or anatomy. Skirts and shorts must be worn at a level that is no more than 2 above the knee. Students cannot wear garments that will expose their bare midriffs. When students are engaged in sports activities shorts must be worn at a length that is no shorter than mid-thigh. Male students are strongly encouraged not to wear earrings. Students must wear the MSEIP T-shirt at all times when they are attending an off-campus MSEIP sponsored activity. USE OF ELECTRONIC EQUIPMENT/ACCESS TO CELL PHONES Students cannot use cell phones, radios, headphones, CD players, computer games, and personal electronic devices during their participation in any MSEIP sponsored classes and activities. Parent who need to contact their student are strongly encouraged to call the main office. Students may also contact MSEIP staff to make emergency phone calls at anytime they are involved in MSEIP activities or classes. Cell phone must be kept in the off mode while students are on campus or participating in MSEIP activities. ENRICHMENTS Students are required to attend one enrichment per quarter. We ask that your child not use cell phones or bring: radios, headphones, CD players, computer games, personal electronic devices or large amounts of money to any Program enrichment. If you need to contact your child, our staff is equipped with phones for emergency use only. Violations of disciplinary infractions as it relates to this protocol could disallow your participation in any enrichment. Page 3

4 TUTORIALS Students are expected to arrive least minutes prior to their scheduled time and come prepared to complete assignments. Students are expected to communicate and cooperate with tutors on all assignments. Students will be required to bring a daily planner and all other assigned materials and text books with them each time they participate in academic classes or workshops. BEHAVIOR EXPECTATIONS $ Students must be prepared to fully participate in all academic activities. Each session, students must bring notebooks, writing utensils, textbooks and completed homework. $ Students should be attentive to, courteous, and responsive to program staff and student leaders during any MSEIP sponsored activities. $ Students misconduct will be handled as follows: First Notice: Written notice will be forwarded to parents providing details of the student s inappropriate behavior. Second Notice: Third Notice: If a second written notice of student misconduct is needed, it may result in a suspension from the program. Students who receive a third notice of misconduct will be dismissed from the program. PARENT EXPECTATIONS/PARTICIPATION $ Parents agree to pick-up their student on time. Parents who are not able to do this must make other arrangements prior to the designated pick-up time. $ Parents agree to provide MSEIP staff with emergency contact information and the names of other people who are approved to pick up their students from the Program. $ Parents are required to come into the building to pick-up and sign-out their student after dark. $ Parents are required to schedule biannual interviews with MSEIP staff to discuss their child=s academic progress. $ Parents agree to support the Program s academic goals and protocol. $ Parents are expected to provide MSEIP with valid and operating emergency phone numbers. TIMELY SUBMISSION OF ACADEMIC DOCUMENTS $ Students are required to submit Grade Reports for every grading period. Parent s/guardian s Signature: Parent s/guardian s Signature: Student s Signature: Staff s Signature: Date: Date: Date: Date: Page 4

5 INTERVIEW Form #3 NAME: SCHOOL: GRADE: ADDRESS/APT. #: CITY, STATE: ZIP CODE: HOME PHONE#: GENDER: MALE FEMALE AGE: Program: MSEIP Project 1. What do you expect to gain from your participation in this program? (Check all that apply.) improvement in math skills improvement in reading skills improvement in writing skills leadership training college opportunities career opportunities better understanding of others participation in activities and events educational resources in Chicago learn more about your self 2. Indicate the subject areas that interest you most: a. b. c. d. 3. Indicate the areas where you need special attention: a. b. c. d. 4. Did you choose to enroll this program? Yes No If not, who influenced you? Parent Teacher Friend 5. How many hours do you study each day after school? 0-1hr 2-3hrs 4-5hrs more How many 6. Do you plan to attend college? Yes No Which one? 7. What colleges/universities are you interested in visiting? Please list: 8. Have you decided on any career or educational goals? Yes no If yes, list them: CAREER EDUCATIONAL Page 5

6 9. Please write an essay on the following topic: Discuss the subjects in which you had difficulty. What factors do you believe contributed to your difficulties? How have you dealt with them so they will not cause problems for you again? In what areas have you experienced the greatest improvement? What problem areas remain? Page 6

7 Page 7

8 Form #4 PARENT CONSENT FOR PARTICIPATION, AUTHORIZATION FOR MEDICAL ATTENTION, and RELEASE FOR LIABILITY Student s Name: Age: Birth Date: Address: Apt #: Phone #: City: State: Zip Code: Father s Name: Business Phone:EXT: Mother s Name: Business Phone:EXT: We (I) are (am) the parent(s) or legal guardian(s) of this child-participant, and hereby grant our (my) permission for him (her) to participate fully in said program, and hereby give our (my) permission for said child-participant to be taken to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. In consideration for being accepted by MINORITY SCIENCE AND ENGINEERING IMPROVEMENT PROGRAM, at Kennedy King College, for participation in academic, sports and enrichment activities, being 21 years of age or older, do for ourselves (myself) and for and on behalf of my child-participant, do hereby release, forever discharge and agree to hold harmless, KENNEDY KING COLLEGE and MINORITY SCIENCE AND ENGINEERING IMPROVEMENT PROGRAM, and the staff thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occurs while said child is participating in the program. We (I), on behalf of our (my) child-participant, hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and program activities involved therein. Authorization and permission is hereby given to said program staff to furnish any necessary transportation, food and lodging for this child-participant. Further, the undersigned agrees to hold harmless and indemnify said Kennedy King College and Minority Science And Engineering Improvement Program, its administrators and employees, for any liability sustained by said initiative as the result of the negligent, willful, or intentional acts of said participant, including expenses attendant thereto. TO MEDICAL PERSONNEL: We (I) authorize the adult, in whose care the minor has been entrusted to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Hospital Insurance Yes No PARTICIPANT Insurance Company Physician s Name Policy Number Phone Number Page 8

9 It is important to have certain medical information so that any emergency may be taken care of as adequately as possible. Please complete the following statements. 1. Date of last physical examination 2. Drug Allergies 3. Last tetanus immunization received 4. Is there a history of (check all that apply) hearing condition, diabetes, asthma, epilepsy, rheumatic fever, other explain: 5. Are there any physical restrictions? 6. Other conditions I understand that should a health emergency arise, I will be notified, but if I cannot be reached by telephone, such medical treatments as deemed necessary by competent medical personnel is authorized. Other than medical emergency, I authorize the University to examine and treat my child in the same way that University students are treated with notification of parents being dependent on the judgment of the physician. (Parent Signature) (Parent Signature) (Date) Name of (please print) Mother: Father: Home Phone # Mother: Father: Work Phone # Mother: Father: Pager # Mother: Father: Cell Phone # Mother: Father: Page 9

10 Form #5 Photo Release Form I hereby grant Kennedy King College, Minority Science and Engineering Improvement Program, permission to use my likeness in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of Kennedy King College Minority Science and Engineering Improvement Program, and will not be returned. I hereby irrevocably authorize Kennedy King College, Minority Science and Engineering Improvement Program, to edit, alter, copy, exhibit, publish or distribute this photo or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless and release and forever discharge Kennedy King College, Minority Science and Engineering Improvement from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization. If the person is under age 18, there must be consent by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of, and do hereby give consent without reservation to the foregoing on behalf of this person. In addition, I give consent for the Minority Science and Engineering Improvement Program and their affiliates to take pictures of me and my family during their events. (Parent/ Guardian s Signature) (Date) (Parent/Guardian s Printed Name) Page 10

11 Page 11