M I G E A R U P S U M M E R A D V E N T U R E A P P L I C A T I O N 2016

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1 M I G E A R U P R E T U R N C O M P L E T E D A P P L I C AT I O N S B Y M AY 20, TO Y O U R M I G E A R U P O F F I C E KING - CHAVEZ PARKS INITIATIVE AND THE STATE OF MICHIGAN S DEPARTMENT OF TALENT & ECONOMICS 1. STUDENT CAMPER AND PRIMARY CONTACT INFORMATION Name of Student: Last First Middle Date of Birth: Age (at the time of camp): Gender: Ethnic Affiliation (circle applicable): 1. African American 2. Latino/Hispanic 3. White 4. Native American, Eskimo or Aleaut 5. Asian American or Pacific Islander 6. Multi-Ethnic Name of School: G.P.A. (2.3 or better): Adult T-shirt Size (circle one): SM MED L XL XXL XXXL Name of Parent/Guardian/Primary Contact: Mailing Address: City: State: Zip Code: Home Phone: Parent Cell Phone: Work Phone: address you check frequently: 2. EMERGENCY CONTACTS (Please provide two additional people, different from the parent/guardian listed above, who would automatically be the first person we contact) First Contact s Name: Relationship: Home Phone: - - Work/Cell Phone: - - ext: Second Contact s Name: Relationship: Home Phone: - - Work/Cell Phone: - - ext: CONTACT YOUR GEAR UP STAFF FOR MORE INFORMATION P: (810) Flint Office P: (989) Campus Office RETURN YOUR COMPLETED APPLICATION TO YOUR MI GEAR UP OFFICE or Fax to (810) OR MAIL APPLICATION TO: MI GEAR UP CENTRAL MICHIGAN UNIVERSITY BOVEE UNIVERSITY CENTER 108 MT. PLEASANT, MI GUSA CAMPUS WEEK JUNE 25 JULY 1 NEW ORLEANS, LA TRAVEL WEEK JULY 10 - JULY 15 WEBSITE CMICH.EDU/CMUGEARUP FACEBOOK CMUGEARUP *STUDENTS WILL BE INVITED TO TRAVEL BASED ON ESSAY, GPA, GU STAFF RECOMMENDATION AND WILL BE NOTIFIED AFTER CAMPUS Week

2 M I G E A R U P FOR MORE INFORMATION CONTACT YOUR GU STAFF P: (810) Flint Office P: (989) Campus Office RETURN YOUR COMPLETED APPLICATION TO YOUR MI GEAR UP OFFICE or Fax to (810) OR MAIL APPLICATION TO: MI GEAR UP CENTRAL MICHIGAN UNIVERSITY BOVEE UNIVERSITY CENTER 108 MT. PLEASANT, MI STUDENT ESSAY In a 250-word essay format, answer and describe the following (preferably typed): 1. The Reach Higher initiative is the First Lady's effort to inspire every student in America to take charge of their future by completing their education past high school, whether at a professional training program, a community college, or a four-year college or university. Why do you want to Reach Higher and advance your education beyond high school? 2. Why do you want to participate in Summer Adventure 2016? 4. PREVIOUS ATTENDANCE Have you ever attended GEAR UP Summer Adventure? (circle one) YES NO Dates:,,, 5.OTHER INFO If there is another camper you are hoping to room with at Summer Adventure, please specify roommate choice: Each student needs to indicate his/her mutual roommate preference. Separate room assignments will be made for male and female students. CMU will try, but cannot guarantee, to accommodate camper roommate requests. FIRST CHOICE SECOND CHOICE THIRD CHOICE 6. PHYSICAL NATURE OF CAMP Throughout the camp, students will be expected to participate in scheduled events/activities. A large portion of the program is physical activity. Activities include, but are not limited to: WALKING tours and class field trips to/from locations on college campus, science and technology projects, and outdoor recreational activities for extended periods of time. It is imperative that students are willing and prepared to be physically active for this camp experience. Can your child withstand the physical nature of camp? (Circle one) Yes or No 7. IMPORTANT POLICIES (Additional Camp Medical Release and Consent Forms will be sent to accepted campers. Forms must be completed and sent to CMU prior to camp). Family Meetings In order for your child to be eligible to participate in this camp you and your child must attend one of the mandatory family meetings. MANDATORY family meetings are for NEW APPLICANTS ONLY. Please select a meeting below: Monday May 23 rd 10:00 am or 5:00 pm Harrison High School (Circle time) Wednesday June 1 st 10:00 am Flint Northwestern Wednesday June 1 st 5:00 pm Flint Southwestern Saturday June 4 th 10:00 am Flint Public Library (Rm 205) Attendance Policy Campers must commit to and complete the full week of the camp to be eligible for participation in the travel week. Camp Rules All school rules apply. Failure to follow rules may result in immediate dismissal from program. If student is immediately dismissed, student will return to home school for parent pick up.

3 GUSA CAMPUS WEEK JUNE 25 JULY 1 NEW ORLEANS, LA TRAVEL WEEK JULY 10 - JULY 15 WEBSITE CMICH.EDU/CMUGEARUP FACEBOOK CMUGEARUP M I G E A R U P 8. TRANSPORTATION AND FIELD TRIPS The Summer Adventure 2016 Camp will use local school district buses and/or charter buses to transport participants to program related activities both on and off campus. Campers are not to use or ride in personal/private vehicles while attending program activities. I authorize program staff to transport my son/daughter/ward for program related activities. I understand that my son/daughter/ward is not to ride in or use a personal/private vehicle while Summer Adventure 2016 activities. Furthermore, I release CMU, its agents and staff from all injuries or liabilities my son/daughter/ward may sustain from program approved transportation and understand that CMU or your local school district will not be held liable for injuries or liabilities my son/daughter/ward sustains from failure to follow program rules. The participant recognizes participation is at their sole discretion and at their own risk. The participant waives, releases, and discharges Central Michigan University, its Board of Trustees and employees from claims, actions, damages, and liability for personal injury or damage relating to their participation in program activities, except where the injury or damage is caused by the sole negligence of Central Michigan University. 9. ADDITIONAL CONSENT AND RELEASE FORMS Additional information for medical treatment, student conduct, and other consents will be forwarded to campers once they are admitted to the program. Parents are responsible for completing and returning the forms to CMU prior to camp in order for their child to attend. I verify that I have reviewed all of the information. I have discussed camp expectations with my son/daughter. I have provided in this document is true to the best of my knowledge. X Parent / Guardian signature Date Street Address City State I have reviewed the camp rules and expectations. I pledge my very best conduct and behavior while attending MI GEAR UP Summer Adventure X Camper signature Date [INCLUDE THIS PAGE IN YOUR APPLICATION]

4 TEA C H E R / P R I N C I P A L R E F E R E N C E R E T U R N C O M P L E T E D A P P L I C AT I O N S B Y M AY 20, TO Y O U R M I G E A R U P O F F I C E 1. REFERENCE Please provide this reference form to your teacher, principal or an adult school staff member (coach, social worker, counselor) to submit on your behalf. A reference form will also be accepted from religious youth activity sponsor and/or youth organizations. Fill in your name and give this form to an adult staff member who knows you well. Applicant s Name: Last First Middle TO THE ADULT STAFF MEMBER Please submit your reference promptly to the school s GEAR UP office. A photocopy of this reference form or another reference letter you have provided for the student is acceptable. We are grateful for your assistance. Reference Name and Position: Work address: Address City State Signature Work Phone or Contact Number: - - ext: EVALUATION Why do you feel this student is a good candidate for MI GEAR UP Summer Adventure 2016? Please make additional comments that would be helpful in deciding on this student s application? RATING: How do you rate this student in the following terms? (Place an x in the box that best represents your rating) Below Above Good Very Good Excellent Attitude toward school work Intellectual ability Initiative/motivation Integrity Influence and leadership ability Ability to get along with others Ability to travel with group Emotional stability Attendance CONFIDENTIALITY: WE VALUE YOUR COMMENTS HIGHLY AND ASSURE YOU THAT YOUR FEEDBACK WILL BE KEPT CONFIDENTIAL RETURN REFERENCE FORM TO YOUR SCHOOL S GEAR UP OFFICE.

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