2017 REGISTRATION FORMS Rosie s Girls STEM Leadership Camps Vermont Tech - Randolph Center Followed by a Leadership Mentor Program For girls (Vermont residents only) entering 9 th -10 th grades fall 2017 STEM activities (science/technology/engineering/math) and Skilled Trades Important: We are accepting applications through April 12 th Below are camp dates and tentative program offerings. Indicate your 1 st and/or 2 nd choice for dates to attend. If you are only able to attend one date - please only check off that date. June 19 June 23, 2017 or July 10 - July 14, 2017 Computer Information Technology Civil & Environmental Engineering Technology Architectural Engineering Technology Construction Management - plus more! Computer Information Technology Mechanical & Manufacturing Engineering Technology Science: Chemistry & Microbiology Architectural Engineering Technology- plus more! Select (check) your 1 st and/or 2 nd choice date(s): June 19-23 1 st 2 nd July 10-14 1 st 2 nd Please fill out this entire packet and return to: Page Spiess, Rosie s Girls Program Leader Adjunct Professor, Science Department Vermont Technical College - PO Box 500 - Randolph Center, VT 05061 Email: pspiess@vtc.edu We will notify accepted students by April 21 st as to their acceptance and or placed on a waiting list. Please understand we have limited space for both of the camps; unfortunately not all those who apply will be able to attend. Accepted students will be required to submit a $75 deposit to reserve a spot in the program. It does not need to be submitted until you are notified of acceptance, and it will be applied toward the total tuition of $375. Contact Information PARTICIPANT INFORMATION Name: Grade (current): School: School attending fall 2017: Email: Phone: Preferred Mode of Contact: email/phone (circle one) Mailing Address: Street Address/PO Box Town State Zip PARENT / GUARDIAN #1 Name: Relationship to Participant: Check if same mailing address as student Street Address/PO Box Town State Zip Primary Phone: Cell Home Work Secondary Phone: Cell Home Work Email Address: Preferred Mode of Contact: email / phone PARENT / GUARDIAN #2 (if applicable) Name: Relationship to Participant: Check if same mailing address as student Street Address/PO Box Town State Zip Primary Phone: Cell Home Work Secondary Phone: Cell Home Work Email Address: Preferred Mode of Contact: email / phone 1
EMERGENCY CONTACTS Name: Phone: Relationship to Participant: Approved for Pick Up: Yes / No Name: Phone: Relationship to Participant: Approved for Pick Up: Yes / No Please Tell Us More! For the Parent/Guardian to fill out: In order to make this the best possible experience for your daughter/ward, we would appreciate your answers to the following questions. Please feel free to use additional space as needed: 1) Why would you like your daughter/ward to participate in Rosie s Girls Residential (STEM) Leadership Program? What do you hope she gains from the program? 2) Has your daughter/ward had any prior experience living away from home? If yes, how long and how many times has she been away from home? How did she manage with living away from home? What tips and information should we be aware of in regards to this? If no, how do you feel she will handle this? 3) Some activities at Rosie s Girls (carpentry, tool & equipment use, engineering equipment, etc.) require participants to work in groups as well as follow safety procedures and explicit directions and to use good judgment/common sense to ensure their own and other participants safety. Please describe any concerns you have about your daughter s/ward s ability to work in a group and follow set procedures and/or to use good judgment. 4) Additionally, girls participate in various vigorous activities such as a ropes course, climbing wall or other sport and fitness. Describe any medical, physical, emotional or other conditions that would limit her ability to participate in sports & fitness areas, if any. Is there anything special we can do to best support your daughter/ward in regards to her social and emotional needs? 2
5) Is there anything else you believe would be important or useful for the Vermont Tech Rosie s Girls staff to know about your daughter/ward? Please feel free to describe additional information (Related to school, including learning differences or classroom needs, family, friends, and including any recent life events). 6) How did you hear about Vermont Tech s Rosie s Girls Camp? (circle which apply) Past participant in Rosie s Girls, Dirt Divas, Rock & Adventure, Women Can Do or Friend Flyer/Poster Online VTC website VWWomen web School (Teacher/Counselor, etc.) Other (please specify) 7) Our Rosie s Girls STEM Leadership Program is followed by a Mentorship Program where each Rosie s Girl is paired with a female professional in a STEM and/or Trades field - over the 2017-2018 academic year. The purpose is to give each girl a chance to learn more about STEM and Trades career path opportunities. Are you willing to have your Rosie s Girl participate? Yes No (see additional information about Mentor Program - in this application) Circle T-SHIRT SIZE (Adult Sizes, Women s Cut)(circle one): S M L XL XXL Thank you for completing the first part of the application. The next portion is for your daughter/ward to complete. We request that you let her complete the questions on her own! 3
For Rosie s Girl applicant to fill out: ROSIE S GIRLS We are so excited that you re interested in Vermont Tech s Rosie s Girls Residential (STEM) Leadership Camp! We want to make this the best possible experience for you and the other girls in the program. We're asking the questions below to get to know you better. We want you to complete the questions below without help from an adult. We really only want to hear from you! There aren't any "right" or "wrong" answers; just be yourself and let us know who you are. Please feel free to use additional space if you need. 1) List five adjectives that you would use to describe yourself (for example: cheerful, silly, etc.) 2) What about your school, classes, other related activities, do you like? What do you find challenging?- 3) What is your level of interest in the STEM areas? (Science? Technology? Engineering? Math?) 4) If you had a free day and you could do anything you wanted, what would be the top 3 things that you would want to do? 5) What did you do last summer? 6) How would you describe your friendships? And how do you feel about being in an all-girl residential (4 nights & 5 days) program? 4
7) Tell us something that you ve done that you are proud of. 8) Imagine yourself 4 to 5 years from now? What do you see yourself doing? 9) How about 10 years from now? 10) What does a leader look like to you? 11) Why do you want to be a part of this program? 12) As part of our Rosie s Girl STEM Leadership Camp each participant will be paired with a female mentor for the 2017-2018 academic year. Are you willing to participate in this amazing chance to learn more about future STEM/trade career paths and how to get there? Yes No 13) Anything else you d like to tell us about yourself? How did you hear about Rosie s Girls? (circle which apply) Past participant in Rosie s Girls, Dirt Divas or Rock & Adventure, Women Can Do or Friend Flyer/Poster Online VTC website VWWomen web School (Teacher/Counselor, etc.) Other (please specify) 5
IMPORTANT The post Mentoring Program Rosie s Girls Mentee Expectations Involvement We assemble talented, experienced and dedicated women professionals in STEM and the trades who are excited to share their wisdom and insight to help offer program mentees greater awareness about career pathways/opportunities. Our Mentors will have been to an orientation program and have been screened for references. Mentors have been selected based on their expertise and background, but most importantly their sincere interest in being a Rosie s Girl Mentor. We try to pair Rosie s Girls Mentees with Mentors who best match Mentees interests so they can help to direct and answer their questions about career pathways for women in STEM and/or the trades. Each Mentee will hear from her Mentor either while at Camp or before the end of September 2017 via phone and/or email. Prior to that date we will have provided each Mentee with a mini-bio of her Mentor with some basic information about her Mentor. We ask that as a Rosie s Girl you fully commit to taking part in the post-camp Mentorship Program offering to gain greater knowledge about potential career pathways with a particular focus on STEM and/or the trades; be a respectful Rosie s Girl Leadership Mentee Role Model; it is a part of being selected for the Rosie s Girls STEM Leadership Camp. The commitment is not too difficult; here is a basic overview/indication of what s involved: 1. Phone or Electronic connections w/ your Mentor once per month - (once paired/assigned - which may be directly following the camp and/or by the fall school year 2017) - to cover such career pathway topics as: o questions about career pathways and opportunities o classes to take now or in the future o setting goals to help you achieve your career path o potential internships, job shadows, and post-secondary education o And other related topics about career connections 2. We will appreciate an in person connection - at the 19 th Annual Vermont Works for Women Women Can Do conference (with approximately 550-9 th 12 th Vermont girls in attendance) - mid October 2017 - Vermont Tech Randolph Center. We would love to have all Rosie s Girls at the event as we have the girls be a part of the program (we do understand that a few many not be able to attend - most girls are able to travel to Vermont Tech with their schools). 3. We will look forward to an in person gathering to celebrate the Mentor/Mentee program - prior to the end of the school year 2018. (anticipated location VTC - Randolph Center) TUITION The tuition for Rosie s Girls is $375. Partial financial aid may be available. To apply for financial aid, please complete the financial aid application form included in this packet. The programs cost approximately $1,300 per participant and are made possible by special educational grant funds. If you are able, please consider making a charitable gift to defray costs for other participants. Once a student is accepted to this program, a $75 deposit will be required to hold a spot in the program. This deposit may be waived if you are applying for financial aid. Full tuition payment is due 14 days before the first day of the program session. Please make checks out to: Vermont Tech. PERMISSIONS Photo Release: (please circle one) I do / do not give permission for photographs and video images of (Participant s name) to be used in the media and in Vermont Tech and Vermont Works For Women and our host site s publications, web-based content, and marketing materials. By not circling a choice, but signing below, Vermont Tech and Vermont Works for Women has permission to use photographs and video images of your child/ward. Program Evaluation Data Collection: (please circle one) I do / do not give permission for my child/ward to complete surveys for the purpose of collecting information about the program s impact and learning how we can continue to make the program stronger. Parent/Guardian Signature: My signature below indicates my permission for my child/ward to participate in all program activities, to attend field trips, to receive medical treatment, and whether to take part in photo or video sessions as indicated above. I agree that if my child/ward is accepted into the camp program I will submit a $75 non-refundable deposit within 7 days of that notice (it is not due until accepted) to hold my camper s place which will be applied to the total fee of $375. And, I understand that full payment is due 14 days before the first day of the program. If my child/ward is accepted off the waiting list, full payment of all fees due will be required before she can attend. I understand that the camp fee is non-refundable after 14 days before the first day of the program session my child/ward is attending. Parent/Guardian Signature Printed Name Date 6
Acknowledgment of Risk and Release of Claims Please review the following with your child/ward and sign for yourself and the participant. In consideration of the services provided by Vermont Tech, I hereby acknowledge, understand, and agree to the following: Nature of the Risk During my daughter s/ward s program experience with Rosie s Girls, she will be engaging in a variety of science/engineering and technology activities as well as some trades-related activities, i.e.: carpentry. She also may be engaged in creative projects such as making music, creative movement, and art projects, as well as playing games outdoors, swimming and riding in vehicles. The risk of property damage or injury, including serious injury or death, exists in many, if not all, of the activities that we may do. Some of the risks are inherent to the activities, and some may be unknown or unanticipated. I agree to accept those risks and voluntarily have chosen to have her participate in spite of the risks. I understand that my daughter/ward will be using power tools and machinery and that it is very important for her to follow all safety instructions she is given. Vermont Tech will not be able to maintain constant supervision of her or the other girls in the program, and she is expected to pay attention to her own safety. My daughter/ward is also expected to follow any rules or directions that may be given, as well as common sense safety precautions. I understand that she may get dirty or sore or may damage her clothing or other property. Release I, for myself, my family members, my heirs, my assigns, and any other person acting on my behalf, hereby release and forever discharge Vermont Tech, its employees, volunteers, directors, and agents from any and all liability, action, cause of action, and claim or for any injury, loss, or damage that may arise out of my participation in the Rosie s Girls program. This release specifically includes, but is not limited to, any claim for negligence or gross negligence by Vermont Tech, its employees, volunteers, directors, or agents. Hold Harmless and Indemnification I agree to indemnify and hold harmless Vermont Tech, its employees, volunteers, directors, and agents from any and all liability, costs, expenses, or damages, including the costs of defense, attorney s fees, and expenses in connection with my participation in the Rosie s Girls program, as well as all costs or attorney s fees incurred to enforce this agreement. General Terms I agree that any dispute that may arise under this agreement shall be brought only in Vermont and shall be governed by and construed under the laws of the State of Vermont. If any portion of this agreement is found to be illegal, void, unenforceable, or against public policy, the remaining portions of the agreement shall not be affected and shall remain in full force and effect to the fullest extent permissible by law. Signature of Parent or Guardian I have read, understand, and agree to all of the above. I have reviewed the above provisions with my child/ward, and I give consent for my child/ward to participate in Rosie s Girls Overnight STEM Leadership Program at Vermont Tech and to participate in post Program/Camp - Mentorship Program through the end of the academic school year June 2018. I agree to all the terms and conditions above, including the release, indemnification, and hold harmless provisions, for myself, my child, and our heirs, assigns, or other persons or entities acting on behalf of myself or my child. Signature Printed Name Date For myself and my child/ward Signature of Participant I have read this agreement and promise to fully commit and take part in the Rosie s Girls Overnight STEM Leadership and post Mentorship Program. Signature of Participant Printed Name Date Participant - Rosie s Girl Overnight STEM Leadership Program Camp and Mentorship Program 7
2017 PARTICIPANT MEDICAL FORM This medical form must be completed and signed by both a parent/guardian and a physician. Please submit this medical form WITH your application, filled out to the best of your knowledge. It is your responsibility to submit a FINAL copy of this filled form WITH doctor s signature no later than 14 days before the start of camp. Participants will not be allowed to attend without this completed form. Failure to complete this form in its entirety and to the best of your knowledge could result in your child/ward either not being considered for camp or could be sent home early from camp. We must be notified of any and ALL medical issues in order to provide a safe and secure experience for all attendees. PLEASE NOTE: A FINAL COPY OF THIS FORM CANNOT BE ACCEPTED WITHOUT A PHYSICIAN S SIGNATURE. PARTICIPANT'S NAME: DATE OF BIRTH: SEX: HEIGHT: WEIGHT: Rosie s Girls may involve using hand-held power tools and welding equipment, as well as physical activities such as a ladders, swimming, and outdoor games. Is there anything we should know for your child/ward to safely engage in these activities? Has the participant been treated for any medical problems in the following areas? Seizures Length of seizure Cardio Vascular Restrictions Orthopedic Observations Restrictions Pulmonary Restrictions Asthma Medications? Inhaler? Any limitations with sight or hearing? Does the participant wear corrective lenses? Does the participant have any contagious or infectious diseases? If yes, explain Has the participant been exposed to any contagious or infectious diseases in last 6 months? Be specific: What dietary restrictions does your girl have, if any? ALLERGIES: Has the participant had any allergic reactions to the following (be specific) - If so, list in detail the reaction: Drugs: Reaction: Insect Bites: Foods: Other: Other: Reaction: Reaction: Reaction: Reaction: Does the participant need to carry an epinephrine pen for any allergies? Yes No If yes, which allergy? 8
MEDICATION: Please list all medication the participant is currently taking (or attach a current medication schedule for this person): MEDICATION DOSAGE SCHEDULE 1. 2. 3. 4. Please describe any other conditions about which program staff should be aware, including social and/or emotional needs: DATE OF MOST RECENT EXAM: (NOTE: Most recent exam must be within last two years.) **PLEASE NOTE: THE FINAL COPY OF THIS FORM CANNOT BE ACCEPTED WITHOUT A PHYSICIAN S SIGNATURE** PHYSICIAN S NAME (please print): TITLE (circle one): MD PA NP Complete Address: Phone(s): PHYSICIAN S SIGNATURE: DATE: MEDICAL TREATMENT I give Vermont Tech staff consent to provide medical treatment (within the scope of their training) to my daughter/ward, make decisions about her immediate medical care and, if necessary, either take her or arrange for her to be taken (by Emergency Medical Services) to the nearest emergency room to receive emergency medical treatment. I give permission to the medical personnel selected by Vermont Tech staff to provide routine health care; to administer x-rays, routine tests and treatment; to release any records necessary for insurance or treatment purposes; and to provide or arrange necessary transportation for my child or ward. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Vermont Tech staff to secure and administer treatment, including hospitalization, for my child or ward. Your insurance company: _ Policy number/name of holder: I hereby give permission for Vermont Tech staff to give my child/ward over the counter medications according to standard dose: Ibuprofen (e.g., Advil) YES NO Acetaminophen (e.g., Tylenol) YES NO Diphenhydramine HCl (e.g., Benadryl) YES NO Parent/Guardian Signature: Date: 9
In case of Medical emergency: Parent/Guardian #1 name and home & cell phone: Parent/Guardian #2- name and phone numbers: 10
2017 FINANCIAL AID APPLICATION Financial aid may be available on a limited basis. The amount provided is determined by family need, and the amount of aid remaining at the time Vermont Tech receives your application. Name of Participant: Name of Parent/Guardian: Please answer ALL questions on this form in order to be considered. 1. Does your child receive free/reduced cost lunch at her school? Free lunch Yes or Reduced lunch Yes: 2. Do you receive support from the Department of Children & Families, Economic Services Division (ESD)? This includes Food Stamps and TANF support. No Yes, 3SquaresVT, Reach Up 3. What is your monthly household income? $ 4. How many household members are dependent on this income? # 5. How many of these household members are less than 18 years of age? # 6. Please check all that apply: One or more family members have a disability or have been ill One or more adults is unemployed or under-employed Financial difficulty related to divorce or separation One or more adults is a college student or studying for a GED Debt payments that are difficult to meet Mortgage is more than 30% of income Credit card payments Student loan debt We cannot afford the tuition without help 7. Is there anything else you would like us to know in determining financial assistance? (Please use the back of this form.) ALL QUESTIONS ON THIS FORM MUST BE ANSWERED IN ORDER FOR YOUR APPLICATION TO BE CONSIDERED. Applying as early as you can is helpful. Please call us if you have any questions about your application. What is the maximum you feel you could pay towards the total fee of $375? Although we cannot guarantee financial assistance will equal your request, you must answer this question in order for us to process your application. We do have a minimum of $ 75. Parent/Guardian Signature Date All information on this form will be kept confidential and will be used solely to determine financial aid 11