HMONG STUDENT ASSOCIATION UNIVERSITY OF CALIFORNIA IRVINE HIGHSCHOOL OUTREACH PROGRAM HMONG INSPIRING TO GAIN HIGHER EDUCATION & RECRUITMENT

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1 Hello aspiring student, We, the Hmong Student Association at the University of California, Irvine (HSA UCI), would like to invite you to our fourth high school outreach, Hmong Inspiring to Gain Higher Education and Recruitment (H.I.G.H.E.R.). This two day, one night program is specifically intended to encourage and motivate high school Hmong students to pursue higher education. Through various workshops and activities, we hope to recruit these underprivileged students, who come from low-income families, to continue their education, follow their dreams and reach their fullest potential. For this event, we will be providing very limited transportation. If you are an applicant in need of a ride, transportation is first come, first serve, so it is in your best interest to apply as soon as you possibly can. If you are able to find your own transportation to and from UC Irvine, please let us know of that below. If you do not have transportation, we highly recommend that you carpool with another accepted application. However, our HSA members will be providing and hosting the housing arrangements. By doing so, students will have the opportunity to experience how college students live. Although our program is aimed at Hmong students, everyone is highly encouraged to apply. Applications are due (postmark) by 11:59 on Friday, January 13 th, Please send in your applications to the or mail to the address below! We are excited to meet you, Hmong Student Association University of California, Irvine Event: Hmong Inspiring to Gain Higher Education & Recruitment (H.I.G.H.E.R.) Host: Hmong Student Association at the University of California, Irvine (HSA UCI) Where: University of California, Irvine (UCI) When: Saturday, February 18, 2017 & Sunday February 19, to: ucihsahso@gmail.com Mailing address to: Gaosheng Lee 73 Stanford Ct Irvine, CA CHECKLIST Personal Information, High School Information, & Permission Emergency Contact & Medical Information Rules and Regulations & Release of Liability, Waiver of Claims, and Indemnity Agreement Essay Questions and Short Answers CONTACT US: Facebook ~ ~ ucihsa@gmail.com or ucihsahso@gmail.com

2 PERSONAL INFORMATION *Required *First Name: *Last Name: MI: * of Birth: / / Ethnicity(ies): *Gender: *Mailing Address: *City/State/Zip: *Home Phone: ( ) *Cell Phone ( ) *Texting: Yes No * *Allergies/Medications/Other Needs: *Are you able to provide your own transportation to UCI? Yes, I am able to provide my own transportation. No, I cannot provide my own transportation. HMONG STUDENT ASSOCIATION *If yes, are you able to carpool other accepted applicants? Yes, my driver is willing to carpool other accepted applicants. No, my driver is not comfortable carpooling other accepted applicants. HIGH SCHOOL INFORMATION *Name of High School: *City of High School: *Year in High school: Freshman Sophomore Junior Senior PERMISSION I, hereby give permission to my son/daughter, * to participate in HAS s H.I.G.H..E.R. program, which will take place at the University of California, Irvine from Saturday, February 18, 2017 to Sunday, February 19, I am aware that he/she will be staying a day with trained volunteer hosts that have been trained on proper protocols. I also understand that I MUST provide transportation to and from the pick-up/drop-off location, unless my son/daughter has his/her own means of transportation. * * Signature of Parent * Parent Name (PRINT)

3 EMERGENCY CONTACT Contact Person 1 *First Name: *Last Name: MI: *Relationship: Phone Number: ( ) Contact Person 2: *First Name: *Last Name: MI: *Relationship: Phone Number: ( ) MEDICAL INFORMATION *Family Doctor s Full Name: *Phone: ( ) *Insurance Carrier & Policy Number: I notify the Hmong Student Association of the following: *Any allergic reactions (medications, foods, plants, insects, etc.): *Any physical limitations or special medical conditions: *Any prescribed medication that will need to be taken at the event: Informed Consent for Emergency Treatment: In the cast of an emergency and if I cannot be reached, I authorize the HAS at UCI to obtain whatever medical treatment he/she deems necessary for the welfare of my child. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of aid emergency treatment regardless of whether or not my medical insurance would cover for such charges and fees. * * Signature of Parent/Guardian

4 RULES AND REGULATIONS 1. Do not bring any type of weapons, firearms, alcohol, or non-prescribed drugs to the program. They are strictly prohibited. 2. Please show respect to yourself, others, student leaders, and the campus. Respect your host s residential place. Do not cause damage to housing property. You will be responsible for any damage you cause. 3. You must stay with and listen to your housing host/group/student leader(s) at all time. Wandering off or leaving the program without the consent of an HSA student leader is prohibited. 4. All participants must dress appropriately and equivalent to the standards of their high school dress code. I have read and understand the rules and regulations provided on this form. By signing this form, I fully agree to participate in HSA UCI s High School Outreach rules and regulations stated above. I am aware that if I violate any rules and regulations, my participation in the program can be terminated and I can be sent home. * * Signature of Participant * * Signature of Parent/Guardian (if participant is under 18) RELEASE OF LIABILITY, WAIVER OF CLAIMS, and INDEMNITY AGREEMENT I, *, hereby affirm and acknowledge that I am Full Name of Participant aware of the inherent hazards and risks associated with the activities of which I am about to engage in. I acknowledge that any loss or injury suffered by me or to my property because of my participation in any activity or use of equipment or facilities is my sole responsibility. The Hmong Student Association, members of the Hmong Student Association, or the University of California, Irvine will not be held liable for any such loss or damage to my person or property. In addition, I also give permission for the Hmong Student Association to take pictures of the event that includes me in it. I HEREBY RELEASE AND HOLD HARMLESS THE HMONG STUDENT ASSOCIATION, MEMBERS OF THE HMONG STUDENT ASSOCIATION, AND THE UNIVERSITY OF CALIFORNIA, IRVINE WITH RESPECT TO ANY AND ALL INJURY, DEATH, OR LOSS OR DAMAGE TO PERSON OR PROPERTY WHETHER CAUSED BY NEGLIGENCE OR OTHERWISE. * * Signature of Participant * * Signature of Parent/Guardian (if participant is under 18)

5 ESSAY QUESTIONS AND SHORT ANSWERS You may write your responses below or type/write on a separate sheet of paper *What is your greatest achievement thus far, either professional or personal? (100 words min 200 words max) *Describe one aspect of being Hmong that you struggle with. Explain why and how. For those who aren t Hmong, what is one aspect within your culture that you struggle with? (100 words min 200 words max) *Who or what inspires you, and why? (100 words min 200 words max) *Tell us something you believe makes you stand out from other applicants that you have not yet shared with us. (100 words min 200 words max) *If you could sum up your life in one song, which song would it be and why? (100 words min 200 words)