Alpha Kappa Alpha Sorority, Inc. Rho Mu Omega Chapter in conjunction with DC Pearls III Foundation, Inc.

Transcription

1 Alpha Kappa Alpha Sorority, Inc. in conjunction with DC Pearls III Foundation, Inc. Historically Black Colleges and Universities (HBCU) Tour 2015 Information and Registration Packet Tour dates: Sunday, November 8- Friday, November 13, 2015 Depart/Arrival times and place: Depart (Sunday, November 8 at 5:00 am): Carter Barron Amphitheatre on November 8, 2015, 4850 Colorado Ave NW, Washington, DC (16 th & Colorado Ave) Arrival (Friday, November 13, 2105 at 7:00 pm): Carter Barron Amphitheatre on November 13, 2015, 4850 Colorado Ave NW, Washington, DC (16 th & Colorado Ave) Eligibility and Requirements Students must: attend a public, private, or charter school in the Washington, D.C. metropolitan area currently be enrolled in 10 th, 11 th or 12 th grade complete and submit two (2) copies of the Academic Teacher Recommendation Form (attached in the packet) Answer and complete the student expectation form (attached in the packet) provide an official copy of their transcript (seniors only)provide a copy of their most recent report card (sophomore and juniors only) submit a completed application packet and checklist. Incomplete applications will not be accepted. Tour Schools: A sample of the schools to be visited during the 2015 HBCU College Tour include: Allen University, Benedict College, Claflin University, Clark-Atlanta University, Elizabeth City State University, Fayetteville State University, Hampton University, Morehouse College, Shaw University, South Carolina State University and Spelman College. PLEASE NOTE THAT OUR TOUR SCHEDULE IS SUBJECT TO CHANGE BASED ON THE SCHOOL S AVAILABILITY. THIS IS ONLY A SUGGESTED LIST OF SCHOOLS TO BE VISITED. 1

2 Tour Cost(s): The cost per student for 2015 HBCU College Tour is $425 and includes breakfast, dinner, transportation, and hotel accommodations. Students will need money to purchase lunch each day, while on the tour. A non-refundable deposit of $ is due on Monday, September 14, 2015 and will hold the student s seat. Suggested Payment Schedule: $150 non-refundable deposit is due before or on Monday, September 14, 2015 $150 payment is due Saturday, October 3, 2015 Final payment: $125 is due at the final meeting on Monday, October 26, 2015 Please make checks, cashier check or money orders payable to: DC Pearls III Foundation, Inc. Please return payment & completed registration forms to: Alpha Kappa Alpha Sorority, Incorporated DC Pearls III Foundation, Inc HBCU Tour P.O. Box Washington, DC Payments can also be made in person at the Meetings/Workshops. Cancellation and Refund Policy: Requests for cancellation and refunds require a written request and must be received by Friday, October 9, No cancellations or refunds will be processed after Friday, October 9, 2015 which is approximately one month before tour departure. Note: deposits are nonrefundable. HBCU College Tour Orientation Meetings & Workshops: There will be three (3) important Orientation Meetings/Workshops: Monday, September 14, 2015: Initial Orientation Meeting: 7pm to 8pm Brightwood Park United Methodist Church 744 Jefferson Street, NW Washington, DC Saturday, October 3, 2015College Prep/Financial Aid Workshop: 10am to noon IDEAL Public Charter School 6130 North Capitol Street NW Washington, DC

3 Monday, October 26, 2015 Mandatory Final Orientation: 7pm to 9pm (ALL FEES AND PAPERWORK ARE DUE) Brightwood Park United Methodist Church 744 Jefferson Street, NW Washington, DC If you have questions, please contact: Parents, please review and sign the attached application. Your signature indicates that you are aware of your student s intentions to participate in the 2015 College Tour. Your signature also indicates that you are aware of the tour fee of $425.00, and your attendance at the mandatory meeting(s) as stated on this information sheet. Please note that participation on the 2015 College Tour is contingent upon receipt of all application materials, teacher s recommendations, payment of all fees, and attendance at mandatory events associated with this tour. Please use the checklist included in this packet to assist in submitting a complete application packet. A copy of your completed checklist MUST be submitted as the cover to your application. 3

4 Alpha Kappa Alpha Sorority, Incorporated in conjunction with DC Pearls III Foundation, Inc. Historically Black Colleges and Universities (HBCU) Tour 2015 Information and Registration Packet Please complete and place this checklist on top of your Registration Packet STUDENT S NAME: Please use this checklist to ensure you are submitting a complete Registration Packet. Check each box and enclosed this sheet on top of your packet. Please Note: All paperwork and fees are due by the last Orientation Meeting. Application complete with Parent/Guardian signature/essay question Notarized medical form Official transcript submitted (SENIORS ONLY)/ most recent report card Two (2) academic teacher recommendation forms sealed in a separate envelope Signed School Consent Form Student Essay questions Copy of student s school ID/photo ID Copy of Student s Medical Insurance Card Declaration signed by parent and student Tour Rules reviewed and signed by parent and student Deposit ($ ) Tour Fee $ (amount paying) 4

5 Section I: Personal Information Alpha Kappa Alpha Sorority, Incorporated in conjunction with DC Pearls III Foundation, Inc. Historically Black Colleges and Universities (HBCU) Tour Application Return To: Alpha Kappa Alpha Sorority, Inc., Attn: D C Pearls III Foundation, Inc. (2015 HBCU Tour) P.O. Box 91436, Washington, DC Please print all information Student s Last Name First Name Sex Home Address Apt# City State Zip Code Address Home telephone # Cell Phone # Name of parent or guardian Address, if different City State Zip code Home telephone number Work telephone # Parent s Address Relationship to student Section II: School Information Current High School Grade Address City State Zip code GPA as of (date) (Students must provide a copy of his/her June 2015 Report Card and a copy of his/her current high school picture identification card) 5

6 Guidance Counselor s Contact Information: Name Office # Seniors: Please list the colleges to which you have applied: List: What major course of study are you considering? Have you taken the PSAT/SAT/or ACT exam? (circle) If not, when will it be taken? Please list any special awards, recognitions, or citations you received for academic achievement or extracurricular activities (please use additional paper if needed). Are you currently involved in after school activities? If yes, please list. Please use additional paper if needed. Have there been any disciplinary actions taken against you in the past two (2)years? Have you ever been suspended from your current or previous schools? If yes, please explain. Please use additional paper if needed. 6

7 Section III: Medical History and Information (Student(s) MUST have medical insurance coverage to participate in the HBCU Tour) Student Medical Care Authorization THIS FORM MUST BE COMPLETED BY THE PARENT/GUARDIANPLEASE PRINT AND USE BLUE OR BLACK INK Insurance Information Insurance Carrier: Policy Holder s Name: Policy Holder s Relationship to Student: Policy No.: Group No.: Phone No.: ***STUDENT MUST BRING INSURANCE CARD ON THE TOUR AND A COPY MUST BE PROVIDED WITH APPLICATION***** Medical Information Primary Care: Physician's Name Address: Telephone Number: Primary Dentist: Address: Telephone Number: 1. Emergency Contact Emergency Contact Information Emergency Contact Relationship to Student: Last Name First Name Home # Work # Cell # 7

8 2. Emergency Contact Emergency Contact Relationship to Student: Last Name Home # First Name Business # Cell # Prescription and over-the-counter medication List the full names of all of the prescription and over-the-counter medications currently being taken by your child. Copy the information from the containers when completing the charts below. Name of Medication Dosage Frequency Taken Reason for Taking Allergies List the names of any medications and food allergies your child may have. Please include the type of allergic reaction your child will experience. Medication Reaction Food Reaction Students should be in possession of only the medication listed on this form while on the tour. All medications must be in original bottles/containers. Chaperones will not be responsible for administering any medication. General Medical Information: yes no yes no yes no asthma / diabetes / high blood pressure / convulsions/seizures / heart trouble / allergies / Other medical conditions that may limit the student s full participation in this tour :(Please be specific- -any special accommodations, such as vegetarian meals, use of a wheelchair, etc.) List any physical conditions that may limit the student s full participation in strenuous walking tours: 8

9 (be specific) Please list any behavioral conditions that may limit the student s full participation in this tour (bespecific) Note: Attach a photo copy of your child s medical card to this application. Parent Authorization: This health history is correct so far as I know, and the person herein described has permission to participate in all prescribed activities, except as noted by me. In the event of illness or accident in the course of such activity, I request measures be instituted without delay as the judgment of medical personnel dictates. Therefore, I grant the program that permission to provide any emergency medical services needed if such is necessary. I understand that this emergency treatment is to be covered by my medical insurance or myself (parent/guardian). It is further understood that my signature grants permission for any hospital to treat my son/daughter as deemed necessary. Parent or Guardian s Signature Date Subscribed and sworn to be me this day of,2015. Notary Public SEAL 9

10 Section IV: Room Assignment Roommate Preference: if you will be attending the tour with other friends (Please print first and last name) Gender: Male Female Tee Shirt Size: S M L XL 1X 2X 3X Other Section V: Student Essay Questions Students: The following questions should be answered by the student who will participate in the tour. What are your expectations of the College Tour? What are your expectations of college life? Parents: This question is to be answered by the student s parent or guardian What are your expectations of the College Tour? 10

11 Section VI: Student Visitation Consent & Authorized Visitors If there are relatives or friends who would like to visit your student during the tour, please complete this part of the application. Authorized visitors are persons located in one of the cities/colleges that we are visiting. (Please feel free to use a blank sheet of paper for additional visitors.) (1) Visitor's Name: Telephone # home/cell Relationship to student: City/State Location: (2) Visitor's Name: Telephone # home/cell Relationship to student City/State Location: (2) Visitor's Name: Telephone # home/cell Relationship to student City/State Location: My child is/ is not allowed to have visitors Please be specific concerning any visitors concerns: 11

12 Alpha Kappa Alpha Sorority, Incorporated in conjunction with DC Pearls III Foundation, Inc. Historically Black College and University (HBCU) College Tour Application Section VII: ACADEMIC TEACHER RECOMMENDATION FORM (Teacher #1) To the applicant: Please complete the information in part one and then give this form to one of your present academic teachers. Please inform your teacher that upon completion this recommendation should be returned to you in a sealed envelope. Part One Student s Name High School Attending: Part Two To the teacher: The above named student has applied for participation in Alpha Kappa Alpha Sorority, Inc., 2015 HBCU College Tour. Please complete and return this form to the student in a sealed envelope so that it may be submitted with their application packet. This information will be kept strictly confidential. Teacher s Name Title: Please check the following response for each of the following items: BEHAVIOR Consistently appropriate Usually well behaved Seldom appropriate Inappropriate CONCERN FOR OTHERS Deeply concerned Somewhat concerned Self-Centered Indifferent INFLUENCE/LEADERSHIP Judgment well respected Contributes with important input Cooperative with minor affairs Negative RESPONSIBILTY Assumes responsibility well Usually dependable Somewhat dependable Unreliable 12

13 Please list this student s strengths: Any additional information that would prove to be helpful. Specific Recommendation: Recommend Not recommended that this student participate in the College Tour Date Teacher Signature Dept. /Subject 13

14 Alpha Kappa Alpha Sorority, Incorporated in conjunction with DC Pearls III Foundation, Inc. Historically Black Colleges and Universities (HBCU) Tour Application Section VII: ACADEMIC TEACHER RECOMMENDATION FORM (Teacher #2) To the applicant: Please complete the information in part one and then give this form to one of your present academic teachers. Please inform your teacher that upon completion this recommendation should be returned to you in a sealed envelope. Part One Student s Name High School Attending: Part Two To the teacher: The above named student has applied for participation in Alpha Kappa Alpha Sorority, Inc., s College Tour. Please complete and return this form to the student in a sealed envelope so that it may be submitted with their application packet. This information will be kept strictly confidential. Teacher s Name Title: Please check the following response for each of the following items: BEHAVIOR Consistently appropriate Usually well behaved Seldom appropriate Inappropriate CONCERN FOR OTHERS Deeply concerned Somewhat concerned Self-Centered Indifferent INFLUENCE/LEADERSHIP Judgment well respected Contributes with important input Cooperative with minor affairs Negative RESPONSIBILTY Assumes responsibility well Usually dependable Somewhat dependable Unreliable 14

15 Please list this student s strengths: Any additional information that would prove to be helpful. Specific Recommendation: Recommend Not recommended that this student participate in the College Tour Date Teacher Signature Dept. /Subject 15

16 Alpha Kappa Alpha Sorority, Incorporated in conjunction with DC Pearls III Foundation, Inc. Historically Black Colleges and Universities (HBCU Tour Application September 1, 2015 Dear Principal/High School Counselor: will be absent from school Monday, November 9, 2015 through Friday, November 13, This student will be participating in an out of town HBCU college tour sponsored by Alpha Kappa Alpha Sorority, Inc.,. During this tour, students will have the ability to visit the campuses of schools such as Hampton University, Benedict College, South Carolina State University, Spelman College, and Morehouse College, just to name a few. Because this is a week-long experience during the school year, students attending the 2015 HBCU College Tour are responsible for all assignments due during that time frame and it is incumbent on him/her to obtain these assignments from the appropriate instructors. Assignment and homework study hall are built in to the schedule of this tour. Please sign below if you recommend this student attend the College Tour. High School Counselor OR High School Principal Date High School Principal/Counselor Name (PLEASE PRINT) Parent/Guardian Signature Arnitra Duckett, 2 nd Vice-President & Program Chairman Alpha Kappa Alpha Sorority, Inc. The members of Alpha Kappa Alpha Sorority Incorporated, and DC Pearls III Foundation, Inc. would like to thank you for supporting this 20 th Annual College Tour, which assists students in making informed decisions regarding their choices for higher education. Your signature acknowledges consent for the excused absences and recommendation for participation. 16

17 Alpha Kappa Alpha Sorority, Incorporated in conjunction with DC Pearls III Foundation, Inc. Historically Black Colleges and Universities (HBCU) Tour Application Section VIII: Declaration I confirm that to the best of my knowledge, the information provided to Alpha Kappa Alpha Sorority, Incorporated, on this application, is true and correct. I also understand that this college tour is being provided as an educational experience for me. I agree to obey all rules and regulations of the tour. I do hereby acknowledge that in the event that I am sent home because I did not obey the college tour rules or I am disruptive to the smooth operation of the college tour; my parents are responsible for my transportation home, on the earliest means of public conveyance. Student's Signature: Date: I confirm that to the best of my knowledge, the information provided to Alpha Kappa Alpha Sorority, on this application is true and correct. My signature below and the enclosed deposit/full payment and application fee indicate that my child has permission to participate in the 2015 College Tour. I understand as the parent or guardian of the above named student, that if my child interrupts the smooth operation of the college tour by disruptive and/or inappropriate behavior or disobeying the rules and regulations they will be sent home In the event, that it becomes necessary, that my child has to be sent home, l will be responsible for his/her transportation. Students will be returned home on the earliest means of public conveyance. Parent/Guardian's Signature: Date: 17