Camp Jumpstart

Summer 2015 Application

Please completeand sign ALL of the information in this packet and submit to your counselorno later than June 5, 2015 to be admitted into the summer program. You may also drop the completed application off at our Texas State University office located at 605 N. Edward Gary, Brazos Hall #111, San Marcos, Texas 78666 or fax it in to 512-245-1896. Space is limited to the first 25 studentsto turn in an application. Late registration will only be available dependent on availability. No student can participate in summer programs without parental consent. Camp Jumpstart will be June 22-23, 2015.

Student Information

Student Name: ______Nickname: ______

Gender: ______Ethnicity: ______Grade(Fall 2015): ______

School: ______

Home Address: ______

(City, State, Zip)

Student Cell Number: ( ) ______

E-mail: ______

Did you or any member of your family qualify for the free or reduced lunch program during the 2014 - 2015 school year?

YesNoNot applicable/I choose not to answer

Student Shirt Size: ______

Parent/Guardian Information

Parent 1/Guardian 1

Name: ______Ethnicity: ______

Home: ( ) ______Cell number: ( ) ______Work: ( ) ______

Email: ______

Parent 2/Guardian 2

Name: ______Ethnicity: ______

Home: ( ) ______Cell number: ( ) ______Work: ( ) ______

Email: ______

Educational Attainment of Parent(s)/Guardian(s)
(circle the highest level completed)
Parent 1/ Guardian 1 / No High School / Some High School / High School Graduate / Some College / Bachelor’s Degree or higher / Don’t know/ Not
Applicable
Parent 2/ Guardian 2 / No High School / Some High School / High School Graduate / Some College / Bachelor’s Degree or higher / Don’t know/ Not
Applicable

Emergency Contact Information: (Used if we cannot make contact with parents/guardians)

Name: ______Relation: ______

Telephone: ( ) ______

Other questions for both students and parents/guardians?

What Colleges/Universities and/or careers are you interested ingetting more information about this summer?

______

Do you have any specific questions/concerns about the college process?

______

______

What is one thing that you would like to learn from attending this institute? ______

Any other questions, comments, or concerns: ______

Camp Jumpstart Rules and Expectations

(Both parents and students are expected to read through these and sign below.)

Our goal for this summer program is to educate all participants on the college access process. We aim for our workshops to be informative and useful for every participant. In order to achieve this, guidelines must be set and expectations must be understood by all. It is our experience that students do best when they know what is expected of them in advance and come prepared.

The guidelines below are not intended to discourage anyone from participating in our program; however, it is this program’s mission to help you develop the skills and knowledge necessary for academic success in high school and later on in college. This can only happen if we are all on the same page. This is a program that requires active participation. Each component serves a purpose and contributes to the entire experience. Those who DO choose to participate must commit themselves to doing their best at all times. Remember, this is for YOUR benefit! Please take time to read through these. It is designed to help students, parents and/or guardians become familiar with program philosophies and expectations.

  • Participants are responsible for finding their own transportation to and from the Texas State University Campus. G-Force mentors and program staff are not allowed to transport participants.
  • Participants are expected to arrive no later than8:30 a.m. If you will be late or absent, it is imperative for you to contact the office as soon as possible. Failure to do so on more than one occasion could result in dismissal from summer program.
  • Students must dress appropriately. Please follow your school’s dress code while participating in the summer program. Participants who show up wearing anything deemed inappropriate by supervision staff will be asked to go home and change. Keep in mind that participants will be doing some walking around campus, and some of the activities will take place outside, so lightweight clothing and tennis shoes would be good to wear. Participants who are cold-natured should bring a light jacket for the classroom.
  • Be respectful of all of your peers and program staff. Please listen to all that they have to share and follow any instructions and requests. Disruptive and disrespectful behavior will not be tolerated. Parents will be contacted if a problem arises, and participant will not be allowed to return at the discretion of the supervision staff.
  • Be accepting of others, celebrate differences. Go beyond first impressions. Make an effort to learn more about others. Discrimination and Racism WILL NOT be tolerated. You will be attending classes on a college campus with people from different backgrounds, yet similar objectives—education. We want to respect the rights of others, just as we expect them to respect ours.
  • All electronic devices must be put on silent or turned off during our workshops. While lessons are in progress, participants should NOT be calling, texting, or surfing internet unless prior approval has been granted by a program supervisor. Parents/guardians will be asked to pick up confiscated devices from the office at the end of the day. If this continues to be a problem, parents will be asked to have a conference with staff.
  • You must respect all Texas State University property. Property damage will be cause for dismissal from the program. Students will have to pay for all property they damage. We strongly emphasize respecting the property owned by the program and university property in laboratories, classrooms and libraries. Any misuse of program resources or university facilities will jeopardize future use. Always, be considerate of other members of the campus community, including Texas State college students, instructors/professors, and other campus staff or personnel.
  • While on college tours, participants are expected to be respectful and attentive at all times. Make the trip worth your time by being respectful and listening to the information being presented by the tour guides and asking questions. Be appreciative of the time and effort provided to you by the staff, guest speakers, and presenters.
  • Drugs are not allowed unless they are prescribed by doctors, cleared with the program staff, and recorded in the student’s file.
  • Absolutely NO alcohol, marijuana, or other illegal drugs are allowed on campus. Anyone suspected of being under the influence of any illegal substance will be dismissed immediately, and parents/guardians will be notified. If necessary, law enforcement will be called.
  • Smoking is not allowedon the university campus. Any minor caught smoking will be dismissed from the program and parents will be notified.

By signing below, you acknowledge having read, understood, and agree to ALL the rules and expectation listed above.

______

Student SignatureDate

______

Parent or Legal Guardian Date

(Required, if student is 17 years of age or younger)

Permission Form and Authorization for Travel and Medical Treatment

Student’s Name___ Social Security Number: ______

I give my child permission to participate in the Camp Jumpstart Camp at Texas State University. He/She has my permission to participate in all educational & recreational activities such as academic classes, seminars/workshops, team-building activities, and field trips, including any scheduled trips out-of-town.

I give my child permission to use transportation provided by the Center for P-16 Initiatives when needed to ensure his/her attendance at scheduled activities and will not hold the Center for P-16 Initiatives or Texas State University responsible for any claims from any liabilities, which might be incurred during the trip.

AUTHORIZATION FOR MEDICAL TREATMENT

I also grant permission to the Director/Coordinator of the Center for P-16 Initiatives at Texas State University, or his/her authorized representative, to furnish such minor medical care as my son/daughter may require. Further emergency treatment, i.e. treatment in the event of a serious illness or the need for hospitalization and/or major surgery, is granted conditional upon understanding that the supervision staff will use all reasonable efforts to contact the emergency reference (parent/guardian) named herein. Failure of such efforts, however, should not prevent the staff from providing such emergency treatment as is appropriate for the well-being of the student listed above. I further understand and agree that Texas State University and the Center for P-16 Initiatives are not legally liable, financially or otherwise, for such emergency treatment, except as provided for by the group medical insurance plan.

Parent’s Signature Date

Please complete the section below for your family’s medical health provider.

Name of Insurance CompanyPolicy

Name of Family PhysicianPhone

Parent/Guardian name:

Wk. #Hm. # Cell # ______Relation

In case of emergency, please contact

Wk. #Hm. # Cell # ______Relation

Please list any personal or family medical history that may be of importance to our records, including allergies and physician prescribed medicine that student is currently taking: ______