Native American Youth Leadership Summer Pipeline to College July 22nd to July 28th, 2018 California State Polytechnic University, Pomona

Native American Youth Leadership Summer Pipeline to College July 22nd to July 28th, 2018 California State Polytechnic University, Pomona

COMPLETE ALL OF THE FOLLOWING FORMS BEFORE SUBMISSION (Applications must be complete before they will be processed). ******DUE: May 18, 2018****** Student Application Parent Information (in application) Personal Progress & College Goals (in application) Tribal Information (in application) One Letter of Recommendation from Counselor, Ed. Director (avoid family relations) Copy of Unofficial Transcript Upon acceptance, you will be sent the following forms: Parent Consent Form Medical Consent & Health History & Medical Insurance Card Program Policies & Procedures

YOU MUST FOLLOWING A COMPLETE INCLUDE THE DOCUMENTS FOR APPLICATION: Copy Of Current Unofficial High School Transcript Copy Of Medical Insurance Card One Letter of Recommendation from a counselor, teacher, tribal education coordinator (letter cannot be from a relative) Mail or fax your completed application to: Dr. Sandy Kewanhaptewa-Dixon or Erica Ben Native American Pipeline Office, Bldg. 94-261 3801 West Temple Ave. Pomona, CA 91768 Phone:(909)869-5274 Fax: (909) 869-3951 SCAN: to sldixon@cpp.edu Questions For any questions regarding the pipeline or its application process please\ contact Erica Ben, Cal Poly Pomona s Community Liaison or Dr. Dixon. Dr. Sandy Dixon: (909)869-4594 sldixon@cpp.edu Erica Ben: (909)869-5274 elben@cpp.edu

Cal Poly Pomona Youth Leadership To College Native American Summer Pipeline Student Application (Student, Please complete entire application. If you are accepted, you will be mailed all Consent Forms) Name (Last, First, MI) Date of Birth: Nickname: Male Female Other Age Have you attended this NA Pipeline before? yes no **email address** **Cell Phone #** Social Media Your current home address: Tribal Affiliation(s) Enrolled? Yes No CIB#

If not enrolled, how do you claim affiliation? Tribal letter Parent Enrollment Descent or Lineage papers (please include with application) PARENT INFORMATION Parent/Guardian Name(s): Address: **Parent/Guardian contact phone number(s)** 1. 2. **Parent/guardian Email** PERSONAL PROGRESS & COLLEGE GOALS Your school: Your School District/BIE/Tribal School: Academic Counselor: School Phone Number: Grade level in Fall of 2018: Freshman Sophomore Junior Senior **Please attach your last and most current unofficial or official high school transcript** Have you taken the ACT or SAT? Yes No If not, do you have a future testing date? Date: Current GPA: What would you like your GPA to be? What clubs or organizations are you an active participant? Have you held any leadership positions at your high school? If so, what position?

What year are you graduating from your high school? 2019 2020 2021 2022 1. When you graduate from high school, is college in your future plan? Yes No 2. Do you plan on attending a vocational school 2-year school 4-year school other: 3. Do you have other plans besides going to school? If so, please describe: Describe what you might be doing after graduation from high school? 4. What would you like to study or major in at a university/college? What would you like to learn more about during the Summer Pipeline? 5. Have you ever been on a college campus? Yes No If so, which campus: 6. Have you ever been away from home and family for one week or more? Yes No 7. Are you currently involved within the Native community? (This could be tribal, a school native club, a native organization, etc) Yes No If you answered yes, please describe your involvement on a daily, weekly, or monthly basis:

8. Strands will be offered this year one 1-2 days. Choose your order of interest with 1 being your first choice. Number 1-5: Engineering Hospitality & Management Teaching Urban Planning Environmental Sustainability 9. Attending a summer pipeline to college program can be an exciting valuable learning experience. If you are accepted into this program, do you think you are socially and emotionally prepared to fully participate in this one week program? Yes No. If yes, please tell us why you are ready to attend this pipeline and why your application should be accepted (This is your opportunity to expand on your desire to attend, tell us your strengths and abilities, any leadership skills you may have, and an overall convincing statement of your preparedness to attend this one week summer pipeline). 10. Within our Native teachings, we are taught to "give back" or what is known as reciprocity. What do you have to offer our Native Youth Leadership Summer Pipeline at Cal Poly as a participant? (Here, you can tell us what you are willing to share with us, such as knowledge about your tribe, traditional or pow wow dancing, beading, storytelling, athletic ability, artistic skills, poetry, academic knowledge, computer literacy, etc). **You may type and attach your response to questions 8 and 9.** We encourage you to bring a sibling or friend if this is your first time. Parents, we accept ages 14-17. Need more information, please email Dr. Dixon at sldixon@cpp.edu. ARE YOU APPLYING TO BE A JUNIOR MENTOR? (Previous participant) 1. A one page letter must be included on why you want to be a Junior Mentor, your qualifications, your experience in leadership positions, your college pathway, and why you should be chosen as a NA Pipeline Junior Mentor.