*We strongly urge having this checklist on your refrigerator* Checklist of To Do s & Important Forms

Transcription

1 Checklist & Forms *We strongly urge having this checklist on your refrigerator* Checklist of To Do s & Important Forms Return Tuition Payment Form (page 18)and applicable payment. Return Parental Permission Form (page 16). Make an appointment with your child s pediatrician. Make travel arrangements with airline, train, bus, etc. within approved dates and times (please refer to Campus-Specific Information on page 25). Return Summer Transportation Form (page 23), including any overnight and shuttle request information. Return Medical Information Form (pages 19 and 20)with a copy of both sides of your Medical Insurance ID Card. Return Physician s Signature Form (page 21). Pay tuition balance. Submit Course Change Request Form (page 24) - optional. Submit Roommate Request Form (page 22) - optional. Internet Fee (refer to Campus-Specific Information (page 25) for rates; a blank check made out to JSA works best). Room Key Deposit(s) (refer to Campus-Specific Information for rates; a blank check made out to JSA works best). Authorization to visit/take student off campus - optional. Make arrangements for rental computer (strongly suggested if you do not have your own computer). Congressional Workshop Forms and Assignment (this will be ed to you in June). Date Due Immediately Immediately Immediately Immediately Immediately June 1, 2014 June 1, 2014 Please refer to page 17, your course selection is not guarenteed until your tuition is paid in full June 1, 2014 June 1, 2014 June 1, 2014 Bring on Opening Day Bring on Opening Day Complete by Opening Day Bring on Opening Day Forms may be submitted separately. When sending forms or payment, please use one of these methods: 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 15

2 Parental Permission Form Student Information I will be attending the 2014 at: Georgetown I Georgetown II Princeton Stanford UVA Student Name Home Address City State Zipcode Phone Gender: Male Female Age Birth Date / / (mm/dd/yyyy) High School Social Security Number - - (Necessary for access to government buildings) Parent Statement High School Graduation year: City and State (or country) of Birth (Necessary for access to government buildings) I have read the Orientation Guide, and I agree to allow my son/daughter to attend the 2014, subject to all rules governing conduct both on and off campus. I understand that my son/daughter may be sent home during the session for any serious conduct violations or for health reasons. I understand that if my child withdraws early from the program, or if he/she is sent home for health reasons or for violations of the rules and regulations of the, the university, or any public law, that no refund will be given and no academic credit will be received. This is to authorize JSA Staff to authorize medical personnel to provide necessary medical care to my child. I give permission for the JSA staff to dispense the limited over-the-counter medicines outlined in the medical form and understand my child will be responsible for taking their own prescription medications. I give permission for the nearest or most appropriate medical facility to provide routine health care for my child; to order x-rays, tests or treatment; and to release any records necessary for insurance purposes. In the event I cannot be reached during an emergency, I give permission for the physician selected by the JSA staff to secure and administer treatment, including surgery or hospitalization, for the student named above. I give permission for JSA to contact my child s medical provider for the purpose of confirming medical conditions/ treatments or obtaining additional information in order to provide appropriate care. The authorization shall be in effect while my child is a student of the. I understand I am fully responsible for my child s medical costs. I understand and agree that additional costs to house, feed and transport my child home after the last day of their program is my financial responsibility. If my child is delayed for any reason on the last day of their program, I agree to pay $50 per night past that date. Also, I understand this option is to be used only in emergencies and is not available as an optional extension. I understand and agree that photographs taken of my son/daughter while at may be used by the Junior Statesmen Foundation for future promotional purposes. I understand and agree that quotations written by my son/daughter while at may be used by the Junior Statesmen Foundation for future promotional purposes. Date Parent Signature STUDENT STATEMENT - I have read the Orientation Packet and I agree to abide by all the Summer School rules. I understand that in the event of a serious violation of the rules, my parents will be notified and I may be sent home at my own expense, with no refund or academic credit awarded. Date Student Signature The U.S. Department of Education requires that we collect and report race and ethnicity data on our students. The parent or legal guardian of the student is required to answer the following questions. (1) Is this student Hispanic/Latino*? (choose only one) Yes No *(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) (2) What is the student s race? (choose only one) American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, who maintains a tribal affiliation or community attachment.) Asian (A person having origins in any of the peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.) Black or Afican American (A person having origins in any of the Black racial groups of Africa.) Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.) (3) Does this student participate in the federal free/reduced lunch program at his/her school: Yes No 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 16

3 Payment Information The Summer School tuition ($4850 for Georgetown/Princeton/Stanford; $5250 for University of Virginia) covers housing and oncampus meals, guidance and supervision, as well as textbooks and other academic expenses. Students must pay for their own meals during off-campus trips. Option 1: Tuition is due 10 business days after receipt of acceptance letter and Orientation Guide. Option 2: Students who need extra time to pay the tuition may send in a $500 deposit to confirm enrollment in the program with 10 business days after receipt of the acceptance letter. The deposit, minus a $75 administrative fee, is refundable to the student upon written notice received by the Junior Statesmen Foundation no later than 15 days before the first day of their selected program. After submitting the deposit, the following payment schedule is in effect: 90 days prior to the start date of your summer school 25% of tuition is due 75 days prior to the start date of your summer school 50% of tuition is due 45 days prior to the start date of your summer school 75% of tuition is due 30 days prior to the start date of your summer school 100% of tuition is due *Percentage applies to the full tuition amount, excluding scholarships. For fundraising assistance, please contact the Junior Statesmen Foundation office for a Fundraising Manual. Option 3: If paying the deposit poses a hardship, students who are planning to fundraise in their community must take the following steps within 10 days of receipt of their acceptance letter. 1. summerprograms@jsa.org to confirm your decision of Option fundraisingacademy@jsa.org to sign up for one of our biweekly JSA Fundraising Academy Webinars. 3. Start an online fundraising webpage at jsa.org/summerfundraising Partial scholarships are available from the Junior Statesmen Foundation. Students who did not submit a scholarship application with their adminssions materials may submit a scholarship application at any time, as long as it is received no later than May 1, Your course selection is not guaranteed until your tuition is paid in full. PAYMENT OPTIONS For any payment, always include the NAME of the student and the PROGRAM the student is attending (i.e. John Doe, Stanford). BY CREDIT CARD We accept Visa, Mastercard, American Express and Discover. Pay by completing the Tuition Payment Form or by phone at (800) BY CHECK OR MONEY ORDER Please make checks payable to the Junior Statesmen Foundation. Include the name of the student and the program they are attending on the check (i.e. John Doe, Stanford). DOMESTIC OR INTERNATIONAL CABLE Please call (800) or (650) for routing number and instructions. Send all check and/or money orders to: 1411 K St. NW Suite 200 REFUNDS Tuition payments (minus a $75 administrative fee) made by the immediate family are fully refundable as long as the Junior Statesmen Foundation receives notice in writing at least 15 business days before the start of your program. After this date, all tuition fees paid become non-refundable, but will remain on the student s account to be used for any future JSA Summer Programs or events. Junior Statesmen Foundation scholarship funds are not refundable at any time. All refunds must be requested in writing. There will be no refund of tuition for any students who withdraw for any reason before the end of the session or who are asked to leave for disciplinary or other reasons JSA SUMMER SCHOOL ORIENTATION GUIDE 17

4 Tuition Payment Form Student Name Home Address City State Zip Summer School tuition is $4850 for Georgetown/Princeton/Stanford and $5250 for the University of Virginia. Tuition is due within 10 business days of receipt of your acceptance letter and Orientation Guide. However, if it is not practical for you to pay the full amount of the Summer School tuition at the time of acceptance, you may make a $500 deposit to hold your enrollment. The $500 tuition deposit is due within 10 business days of receipt of your acceptance letter to confirm enrollment. After submitting the deposit, tuition is due in full by 30 days prior to the start date of your summer school. Students who are actively fundraising should call our office at (800) Minimum Total The minimum total amount paid excludes any scholarships awarded. Tuition payments (minus a $75 administrative fee) made by the immediate family are fully refundable as long as the Junior Statesmen Foundation receives notice in writing at least 15 business days before the start of your program. After this date, all tuition fees paid become nonrefundable, but will remain on the student s account to be used for any future JSA Summer Programs or events. In accordance with federal tax laws, sponsorship contributions given in your name are nonrefundable. Refunds will not be given to students who withdraw early from the program for any reason, or to those who are sent home because of failure to comply with the rules and regulations of, or any public law. If any service clubs, other organizations or family friends are making a sponsorship contribution in your name, they can mail a check directly to the Junior Statesmen Foundation office with a note indicating that you raised the money. If you have any questions about scholarships or tuition, please contact us at (800) PAYMENT INFORMATION Enclosed is $4850, my full tuition payment (Georgetown/Stanford/Princeton) Enclosed is $5250, my full tuition payment (University of Virginia) Enclosed is our $500 deposit (Refundable minus a $75 administrative fee. See REFUNDS section, page 17 for details) Other amount $ We are paying by: Check (made payable to the Junior Statesmen Foundation) Visa MasterCard American Express Discover Card Number Exp. Date CID # Card Holder s Name Billing Zip Code VISA, MC, DISC: 3-digit code on the back AMEX: 4-digit code on the front Card Holder s Signature Amount to be Charged $ 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 18

5 Medical Information Form, part 1 This form should be filled out by the parent/guardian and returned to JSA by June 1, Student Information Student Name Address Father/Guardian Daytime Phone Evening Phone Cell Phone First Emergency Contact (other than guardian) Relationship to Student Daytime Phone Evening Phone Cell Phone Campus City, State, Zip Mother/Guardian Daytime Phone Evening Phone Cell Phone Second Emergency Contact (other than guardian) Relationship to Student Daytime Phone Evening Phone Cell Phone Medical Insurance All students must bring to campus a photocopy of both sides of your insurance and pharmacy cards (front and back) Medical Insurance Provider Policy/Group No. Address of Insurance Company Name of Policy Holder Employer of Policy Holder Date of Birth of Policy Holder Prescription Card No. Medications You Will Have On Campus (Please note that the Junior Statesmen Staff will only administer Advil or Tylenol and no other medications. If your child is prone to stomach aches, colds and coughing, it is your responsibility to pack whatever over-the-counter medications they might require. Also, the Junior Statesmen Foundation staff will not be responsible for administering necessary prescription medications to your child.) My child does NOT take regular prescription medication at this time. My child DOES take regular prescription medication at this time. Medication Name Medication Name Medication Name Medication Name Return this form WITH the next page to: 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 19

6 Medical Information Form, part 2 This form should be filled out by the parent/guardian and returned to JSA by June 1, Allergies Do not give my child the following medications under any circumstances: My child is allergic to the following medications, food, insect bites, etc. Does your child carry an EpiPen for allergies? Yes No Medical History My son/daughter has the following health problems/special needs of which you should be aware: Does your child have a history of operation or serious illness? Is your child under the care of a psychologist, psychiatrist or counselor? If so, please provide relevant details. Include additional documents if necessary. Is there anything else that we should know about your child s physical or mental state? I signify this medical information is true to the best of my knowledge Date Parent/Guardian Signature Return this form WITH the previous page to: 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 20

7 Physician s Signature Form This form should be returned to JSA by June 1, 2014 To be Completed by Parent/Guardian Student Name Campus Medical History Date of Physical Exam (must be within the last 2 years) Should JSA be aware of any disabilities, dietary restrictions, or mental or physical health issues which the student may have? Describe Yes No Are there any phyisical activities from which the student should be restricted from participating? Yes No Is the student taking any medications? Describe Describe Immunizations: Please attach a separate sheet with all immunizations or provide dates for the shots listed below. DPT 1 st 2 nd 3 rd 4 th MMR 1 st 2 nd Polio 1 st 2 nd 3 rd 4 th Date of last tetanus booster Meningococcus (not required) Hepatitis B (not required) Varicella (chicken pox) (not required) PHYSICIAN S STATEMENT Haemophilus Influenza Type B (not required) Tuberculosis skin test (required for students traveling from outside the U.S.) If positive, can this person participate in the program and not be a danger to himself or others? Yes No Physician s Name, Address and Phone Number To the best of my knowledge, the student is in good mental and physical health, is up to date with required immunizations and should be able to complete and participate in casual recreational activities in a Junior Statesmen program, unless otherwise noted on this form. Date Physician s Signature/Stamp Return this form to: 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 21

8 Roommate Request Form (optional) The housing lists for s will be submitted to the university by early June. If you have a preference for your roommate, please complete this form and return it to us by May 27, The tuition of both students must be fully paid by the deadline if the roommate request is to be honored. Also, both students must submit a request form asking to be roomed with each other. All requests must be in writing. Your Name Please complete the following information Your Address Your Phone Number Your High School High School Graduation Year Name of the person with whom you wish to room Requested Roommate s Phone Number Return this optional form to: 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 22

9 Summer Transportation Form Very important: All students are required to fill out this questionnaire regardless of how you are arriving on campus. Please include a copy of your airline itinerary when you return this form (if applicable). Please refer to the Campus-Specific Information section of this guide (page 25) if you have questions. The form is due June 1, Student Name Student Cell Phone Number (on day of travel) Campus Parent Cell Phone Number (on day of travel) I will be arriving by Adult-Driven Automobile Plane Bus Train I will be departing by Adult-Driven Automobile Plane Bus Train I will need a shuttle on Opening Day Yes No I will need a shuttle on Departure Day Yes No Travel Itinerary Originating Airport Arrival Information (not required if Adult-Driven Automobile was checked) Originating Airport Departure Information (not required if Adult-Driven Automobile was checked) Flight/Train/Bus Number Flight/Train/Bus Number Airline Airline Arrival Time (PST for Stanford, EST for Princeton/Georgetown/UVA) Departure Time (PST for Stanford, EST for Princeton/Georgetown/UVA) a.m. p.m. a.m. p.m. Connecting Flight (if applicable) Connecting Flight (if applicable) Yes No Yes No Connecting through city Connecting through city Flight/Train Number Flight/Train Number Airline Airline Destination Airport (i.e. Dulles, Reagan, SFO, Newark) Destination Airport Return this form to: 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 23

10 Course Change Request Form For students who have already taken an American Government, AP U.S. History and/or Speech Communication course, we recommend choosing one of the other classes listed below. Freshman Scholars are not eligible for these courses. Return this form by June 1, Student Name Age High School High School Graduation Year I would like to take the following course Honors Constitutional Law Honors Media & Politics Honors International Relations Speech & Political Communication Advanced Placement U.S. Government Advanced Placement Macroeconomics What grade were in when you took U.S. History? Level of your U.S. History Course Honors Advanced Placement Other (please specify) What was your final grade in U.S. History? A B Other (please specify) Have you taken A.P. American Government at a? Yes No If Yes, in what year and at what campus? Have you taken A.P. American Government at your High School? Yes No What was your final grade in American Government? A B Other (please specify) Please write a brief paragraph on why you would like to take the course you ve selected. Return this optional form to: 2014 JSA SUMMER SCHOOL ORIENTATION GUIDE 24