PCI NVA NSBE, Jr. Pre College Initiative Program

Transcription

1 PCI NVA NSBE, Jr. Pre College Initiative Program Nubian Village Academy ational Society of Black Engineers Application Packet

2 NVA-NSBE, Jr. Pre-College Initiative WHAT IS NSBE, JR. PCI? NSBE, Jr.-PCI is an year round pre-college program hosted by Nubian Village Academy s National Society of Black Engineers. NSBE, Jr.-PCI is targeted towards 3rd 12th grade underrepresented students to provide encouragement, support, and assistance in their pursuit of a college education. The program s aim is to increase the number of underrepresented students who are prepared to enter college; moreover, qualified to pursue majors in engineering, math, science, and other technical disciplines. WHY JOIN NVA NSBE, JR. PCI? Exposure to collegiate life Hands-on activities and Fieldtrips In-depth look at STEM (Science, Technology, Engineering, and Mathematics) curriculums, and career opportunities Build leadership, gain professional experience Attend NSBE conferences, network with current and future engineers Do you plan to go to college or are you contemplating the possibility? Are you interested in engineering, math, science, or computers? If you answered yes! to any of these questions, then you may want to consider attending this annual pre-college program. NVA-NSBE, Jr. invites you to join our chapter. You will participate in a variety of hands-on engineering and science-related activities, as well as sessions designed to enhance your personal development and cultural awareness while interacting with students who share similar interests and goals. You will learn how to prepare for college and identify what courses to take during your high school years. In addition, participation in the program offers opportunities to become familiar with college-life at local Universities and its resources. WHO IS ELIGIBLE? NVA-NSBE,Jr.-PCI is designed for underrepresented students who will be in grades 3rd 12th. WHAT DOES NVA NSBE, JR. PCI INCLUDE? The program consists of 14 events, scheduled over the upcoming school year at Nubian Village Academy. The events include a variety of activities, fieldtrips, workshops, and seminars. Some fieldtrips may have additional fees associated. The Chapter meetings will take place on 2 nd & 4 th Sundays from 2:00p-4:00p throughout the school year. All students are expected to participate in all meetings and events. Tentative dates for the NVA- NSBE,Jr.- PCI fieldtrips will be posted on our website: Students are encouraged to participate over their full academic years.

3 WHAT SHOULD I BRING? Wear our chapter uniform: Navy blue bottom (no jeans), light blue shirt, (navy blue blazer & plaid tie can be order through the school). Please bring your own pencils, pens, paper, and other writing supplies. Students are welcome to bring snacks. A COMPLETE PCI APPLICATION PACKET CONSISTS OF WHAT? A. PCI Application form B. Parent Permission form C. Health Treatment Authorization and Medical forms D. Completed Student Questionnaire E. Chapter Dues $45 Applications must be turned in at Nubian Village Academy. Please send all materials in one packet. Participant will be notified of membership within 10 days. Please note that Incomplete Applications will not be considered.

4 NVA-NSBE, Jr. Pre-College Initiative PCI APPLICATION FORM A complete NVA-NSBE-PCI application packet consists of: A. PCI Application form B. Parent Permission form C. Health Treatment Authorization and Medical forms D. Completed Student Questionnaire E. Chapter Fees $45 Applications must be turned in to Nubian Village Academy. Please send all materials in one packet. Participant will be notified of your membership within 10 days. Please note that Incomplete Applications will not be considered. (Please print neatly) STUDENT PERSONAL INFORMATION: Name Male Female Last First Middle Student ID # Age Date of Birth / / Current School GPA Address Street Apt # City State Zip Code Home Phone # ( ) Student E mail

5 STUDENT PERSONAL INFORMATION: Do you have access to a computer at home? (Please check one) Do you have access to a computer at school? (Please check one) Yes No Yes No Do you plan to go to college? (Please check one) Yes No If you plan to go to college where do think you might attend? What do you think you will major in while in college? PARENT / LEGAL GUARDIAN INFORMATION: Name Daytime Phone # ( ) Place of Employment E mail CURRENT SCHOOL INFORMATION: Name Address Street City State Zip Code Grade Level for (Please circle one) 3 rd 4 th 5 th 6 th 7 th 8 th 9 th 10 th 11 th 12 th T shirt size: Name of Guidance Counselor E mail PLEASE RETURN TO Nubian Village Academy Attn: Nin Aseeya Ra-El NVA-NSBE, Jr Fendall Avenue Richmond, VA Applications are accepted year round.

6 NVA-NSBE, Jr. Pre-College Initiative PARENT PERMISSION FORM This is to certify that my son/daughter, Please print full name of applicant has my permission to participate in the Pre-College Initiative Program sponsored by Nubian Village Academy s National Society of Black Engineers, Jr. (NSBE,Jr.). In addition, this form is an indication that I will support my son/daughter while participating in this program and will ensure that my son/daughter has transportation to and from Nubian Village Academy and that he/she attends every scheduled event. PARENT / LEGAL GUARDIAN INFORMATION: Name Please print Relationship to Applicant Address Street Apt # City State Zip Code Home Phone # ( ) Work Phone # ( ) E mail Parent / Guardian s Signature Date Note: The parent/guardian s signature on this permission form is an indication that NSBE and Nubian Village Academy are not responsible for any liabilities that occur as a result of this event. The student may not participate in the program unless ALL information is filled in on each form and all the required forms submitted.

7 Throughout NVA-NSBE, Jr.-PCI, you will have the opportunity to use photography equipment as a tool for documenting activities. Participants have the option to determine whether they would like their image and/or statements to be included in any of the photographs and/or videos taken by themselves, staff, or other participants in the project. No media containing a participant s image or statements will be used for this program unless a participant and his/her parent/guardian provides permission for us to do so. Please choose one option: I hereby irrevocably grant and convey to Nubian Village Academy all rights, title and interest in and to record my name, image, voice, statements and/or writings including any and all photographic images and video or audio recordings made by Nubian Village Academy in connection with NVA-NSBE, Jr.-PCI. I further irrevocably grant to Nubian Village Academy, its advertisers, customers, agents, successors and assigns, unrestricted rights to use the above mentioned sound, still, or moving images in any medium, including posting on the Internet and World Wide Web, for educational, promotional, advertising, or other purposes without limitation consistent with the mission of the Academy. I agree that all intellectual property rights to the sound, still, or moving images belong to Nubian Village Academy. I voluntarily waive my rights to any royalties, proceeds or other benefits derived from such photographs or recordings. I hereby do NOT grant or convey to Nubian Village Academy, NSBE all rights, title and interest in and to record my name, image, voice, statements and/or writings including any and all photographic images and video or audio recordings made by Nubian Village Academy in connection with NVA-NSBE, Jr. -PCI. This release is effective on the date written below and will remain in effect indefinitely. If individual is less than eighteen (18) years of age, his/her parent or legal guardian must also sign below. Participant Name Participant Signature Date Parent/Legal Guardian Name Parent/Legal Guardian Signature Date

8 IMPORTANT: This form must be completed by the NVA-NSBE, Jr.-PCI participant s parent or legal guardian (P/G) and must be returned along with the acceptance packet in order to participate in the program. Please note that a P/G signature is required in four places on this form. Name Home Address Home Phone Cell Phone DISCLAIMER OF LIABILITY Nubian Village Academy, the Nation Society of Black Engineers, and the staff/volunteers of the Programs do not assume liability for any injuries incurred while attending the NVA-NSBE, Jr.-PCI Program. In consideration of my child s opportunity to participate in this program, I do hereby agree to hold the Nubian Village Academy and its employees harmless and free from any transaction and/or occurrence directly or indirectly associated with my child s participation in the NVA-NSBE,Jr.-PCI. *Signature of Parent/Guardian *Signature of Participant Emergency Release Consent to Emergency Aid & Transportation I hereby give permission that my child,, be given treatment by a staff member at Nubian Village Academy. I also give my permission for my child to be transported by car or ambulance to an emergency center for treatment, and I agree to hold Nubian Village Academy and its employees harmless. Parent s Signature Date Consent to Medical Care and Treatment In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician, and I hold Nubian Village Academy and its employees harmless. *Signature Of Parent/Guardian *Signature Of Participant

9 EMERGENCY CONTACTS: Mother /Legal Guardian Work Phone Cell Phone Home Phone Father /Legal Guardian Work Phone Cell Phone Home Phone INSURANCE INFORMATION: Please supply the following information concerning your family health insurance policy. Insurance Company Name Phone Number Policyholder s Name Policy Number Group Number Policyholder s Address Please return this form in your application packet.

10 We would like to know more about how you decided to apply and attend our program, as well as some of your thoughts about your future. Although we ask for your name, we will keep all of your answers confidential. Name: 1. How did you learn about NVA-NSBE, Jr.-PCI? Teacher/Counselor Extracurricular Program Internet Search High School Graduation Year: Nubian Village Academy Representative Word of mouth Other 2. To what extent did the following factors influence your decision to join NVA-NSBE, Jr,- PCI? Parents wanted me to attend Encouragement from teacher/guidance counselor Wanted to learn more about engineering Wanted to attend fieldtrips Wanted to know more about Nubian Village Academy Wanted to meet new people Wanted to help prepare myself for college Wanted to enhance my awareness of careers in Engineering Not at All 1 A Little 2 Moderately 3 Very Much 4 3. Were you familiar with Nubian Village Academy before you learned about this program? Yes No 4. Who is the greatest influence in helping you make your academic/career decisions? (Select one) School guidance counselor School math teacher School science teacher Relative (who) Other

11 5. From your present knowledge of engineering, what fields of Engineering (Eng) interest you the most? (Select all that apply) Aerospace Eng Computer Science Materials Science & Eng Biological Eng Electrical & Computer Eng Mechanical Engineering Biomedical Eng Engineering Physics Operations Research & Eng Chemical Eng Environmental Eng Science of Earth Systems Civil Eng Information Science, Systems & Technology Other 6. The highest level of education I plan to achieve is (check one): B.S. (Bachelors) M.S. (Masters) Ph.D. M.D. (Medical) Other professional degree 7. Please list any of your relatives who are engineers or scientists (For example, Suzy Smith Mom). 8. List other science/engineering programs or organizations you participate:

12 NVA-NSBE, Jr.-Pre-College Initiative PCI APPLICATION PACKET CHECK LIST PCI Application form Parent Permission form - Please have your parent/legal guardian completely fill out this form. Emergency Release and Medical forms - A treatment authorization and medical form is attached with this packet. We request that you have your parent/legal guardian fill out these forms. Student Questionnaire Chapter Dues: $45 PLEASE NOTE THAT ALL ITEMS ON THIS CHECK LIST MUST BE FULLY COMPLETED AND SUBMITTED FOR YOUR APPLICATION TO BE CONSIDERED PLEASE SEND APPLICATION PACKET TO Nubian Village Academy Attn: Nin Aseeya Ra-El NVA-NSBE, Jr Fendall Avenue Richmond, VA Applications are accepted year round FOR FURTHER INFORMATION NVA NSBE Website Nubian Village Academy (800) NSBE PCI Advisor: Nin Aseeya Ra El (804) [email protected] [email protected] Nubian Village Academy does not discriminate against employees, students, or applications on the basis of race, sex, disability, age, veteran status, national origin, religion, political affiliation, or sexual orientation.. Please feel free to duplicate this application packet