Application Instructions: Read all instructions carefully, incomplete applications will not be considered. The 2017 will be June 26 June 30. Complete all fields in the Summer Institute Application. Print clearly or type. Make sure the email address you submit in the Email address field is valid and is the email address you check on a regular basis. We must also have a way to contact your parent/guardian either by phone or email (preferably both). In addition to the Program Application, you (and your parent/guardian if you are age 17 or younger) must complete the attached Consent Form and Medical Information Form. Review the Program Expectations at the end of this document. Complete the Recommendation form with information on two individuals (not family) we can contact as references. The Summer Institute Application, Consent Form, and Recommendation Form must be mailed together. Send your completed application to: Minnesota Council on Economic Education Attn: Summer Institute Applications 1994 Buford Ave, Ruttan Hall 116 St. Paul, MN 55108 You can also scan and email your application to hans1577@umn.edu or fax it to (612) 625-3186. Please include ATTN: MCEE on the first page if faxing. Applications are due by April 1, 2017. We will review applications as they are received. We encourage you to apply early! Questions about applying? Contact Andrea Hanson at hans1577@umn.edu or (612) 625-3727. Page 1 of 11
Summer Institute Application 1. Student Information Name: Male Female Last First Middle Prefer to be Initial called (circle one) Address: Number and Street City State Zip Home phone: ( ) Date of Birth: Cell phone: ( ) Month Date Year Email address: Make sure this is a valid email address that you check often. We will contact you through this email address. 2. Parent/Guardian Information Parent(s) or Guardian(s) Names: Address: Number and Street City State Zip Home phone: ( ) Work phone: ( ) You must include at least one phone number to reach your parent(s)/guardian(s) Cell phone: ( ) Email: Make sure this is a valid email address that is checked often. Page 2 of 11
3. High School Information High School: Name City State Current Grade Level 9 10 11 Current GPA: How did you hear about the? 4. Additional Information (Please circle all that apply.) Are you eligible for free or reduced-price lunch? Yes No What is your race/ethnicity? (circle all that apply) African American/Black/African (Not Hispanic) Hispanic or Latino American Indian/Alaskan Native Asian/ Pacific Islander Multiracial White (Not Hispanic) Did your one or both of your parents attend college? Yes No Page 3 of 11
5. Personal Statements Please list any activities you are currently involved in (extracurricular activities, sports, work, AVID, community service, etc.): Why is pursuing postsecondary education important to you? Page 4 of 11
Why are you applying for the? Page 5 of 11
Is there anything else that you would like us to know about you? 6. Signature I certify that the information contained in this application is true, complete, and correct. I confirm that I have read the program expectations and will abide by them. By signing this application, I agree to fully participate in the Summer Institute. Signature of applicant: Date: Like all of MCEE s programs, the Summer Institute is dependent on funding. Page 6 of 11
Participant s Name: CONSENT FORM: PARTICIPATION AGREEMENT, WAIVER AND RELEASE Participant s Age on 06.01.2017: Address: Number and Street City State Zip Participant s Phone: ( ) Email: Parent/Guardian s Name(s): Parent/Guardian Phone: ( ) Parent/Guardian Email: I, the Participant (or parent/guardian of Participant) named above, wish to participate in the Minnesota Council on Economic Education (the Program ) at the University of Minnesota Twin Cities. In consideration of such participation, I acknowledge and agree as follows: Risks. The risks of some of the activities involved in this Program may be significant, including the potential for serious injury or death. Rules and personal discipline may reduce the risks, but the risk may continue to exist. Release. I knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for my participation in the Program. On behalf of myself, my heirs, next of kin, successors, assigns, and anyone else who might claim through me, on my behalf, or who might have a claim arising out of, related to, or based upon any disability, death, or loss or damage to person or property I may experience as a result of my participation in the Program, including field trips, I expressly forever release, indemnify and hold harmless Regents of the University of Minnesota, directors, employees, volunteers, leaders, sponsors, Program organizers, promoters, and each of their agents, representatives, successors and assigns, and all other persons associated with the Program ( Releasees ) from any and all loss, cost, expense or other damage of any kind, including but not limited to insurance subrogation and attorney s fees (together and singly, Claims ). THIS RELEASE AND PROMISE APPLIES EVEN TO CLAIMS BASED IN WHOLE OR IN PART ON RELEASEES NEGLIGENCE AND/OR GROSS NEGLIGENCE, TO THE EXTENT PERMITTED BY LAW, BUT NOT RELEASEES WILLFUL OR WANTON ACTS. General. I authorize Program directors, instructors and staff to record photographs or other likenesses of me on videotape, audiotape, film, photograph or any other medium and use, reproduce, modify and publicly exhibit such recordings without limitation or restriction for any purpose. I further consent to use of my name, voice and biographical material in connection with such recordings. I will comply with all Program and participation requirements. Program staff may suspend or terminate my participation in the Program because of inappropriate or disruptive conduct or failure to comply with Program and participation requirements. Transportation. I acknowledge and agree that I am responsible for my transportation to and from the Program. I acknowledge that the Program will provide daily bus passes for transportation on Metro Transit Page 7 of 11
buses at no cost to me. If the Program includes field trips, transportation for those field trips will be provided at no cost to me. I expressly forever release, indemnify and hold harmless the Releasees from any and all Claims associated with my transportation to, during, and from the Program. On Campus. I acknowledge that during the course of the program, there may be opportunities for me to explore the campus on my own or with fellow participating students. I expressly forever release, indemnify and hold harmless the Releasees from any and all Claims associated with my time on campus either to, during, or from the Program. Governing Law and Jurisdiction. The laws of the state of Minnesota shall govern the validity, construction and enforceability of this Agreement, without giving effect to its conflict of laws principles. All suits, actions, claims and causes of action relating to the construction, validity, performance and enforcement of this Agreement shall be in the courts of the State of Minnesota. I HAVE READ THIS LEGALLY BINDING DOCUMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. PARTICIPANT S SIGNATURE Age: Date Signed: This is to certify that I, as parent/guardian with legal responsibility for this Participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child s involvement or participation in the Program provided above, even if arising from the negligence of the Releasees, to the fullest extent permitted by law. PARENT/GUARDIAN S SIGNATURE PHONE #(s) Date Signed: Page 8 of 11
MEDICAL INFORMATION AND RELEASE OF LIABILITY List all medications or medical conditions that the Program s staff and medical emergency service personnel should be aware of. This includes any medications the Participant typically takes during the school year. Also list any behavioral or other information that may be helpful to the Program s staff to assist the Participant in having a positive experience: In case of an emergency, we will contact the participant s parents. If we cannot reach the participant s parents please provide an additional adult that we can contact. A family member (aunt, uncle, cousin), neighbor, or friend. Emergency contact person in case parent(s) cannot be reached: Name: Relation: Phone: * * * * * * * * I understand and agree that some activities occurring as a part of or incidental to the Program may include physical activity. Understanding this, I state that my child has no medical condition or impairment, including the use of medication that might inhibit my child s active participation in the Program. In the case of an injury or medical emergency, I authorize the staff, employees, or instructors of the Minnesota Council on Economics Education and the University of Minnesota Twin Cities to render first aid and/or obtain whatever medical treatment he/she deems necessary for my child s welfare. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of treatment to my child regardless of whether my medical insurance would cover such charges and fees. I have read and understand agree to the terms and conditions of this Release. Print Parent Name: Parent/Guardian Signature: Date: Page 9 of 11
Recommendation Page 10 of 11
Program Expectations Full attendance is expected, Monday through Friday from 9:00 a.m. to 3:30 p.m. Participants are required to attend all scheduled programs and activities. Participants must stay with the class and instructors at all times, unless otherwise permitted. Participants must eat all meals with the class and cannot use breaks or lunch to walk around the campus unsupervised, unless otherwise permitted. Cell phones and personal electronics may be used only during free time or as permitted by the instructors. All participants will be expected to conduct themselves in an appropriate manner, use respectful language, cooperate with the staff, and comply with University policies and rules. Absolutely no drugs, alcohol or weapons of any kind are permitted. Use of tobacco under the age of 18 is illegal and not allowed. The University of Minnesota is a tobacco free campus. Participants are eligible to receive $20 daily stipends for full attendance and successful completion of stated program objectives; stipends will be after completion of the program. Page 11 of 11