summer xl student application - kuspuk.org xl... · © 2017 – 7excel alaska, inc. media consent...

SummerXLCampStudentApplicationPacket

©2017–EXCELAlaska,Inc. 1

StudentInformation

StudentName MailingAddress

City State ZipCode

BirthDate Grade SocialSecurity(neededtoobtaincollegecredit) EmailAddress

StudentStateID#(obtainfromschoolcounselor):

HighSchoolInformation:NameofSchool

Mailingaddress,City,State,ZipCode

TelephoneNumberofSchool(areacodeandnumber)

Pleaseobtainfrom StudentStateID# SAT/ACTScores(iftaken)SchoolCounselor

WorkKeysScores(iftaken)

Pleasechoosethestrand/classyouwouldliketotake.Puta1foryourfirstchoice,2foryoursecondchoice,3foryourthirdchoice,and4foryourfourthchoice.RETURNINGSTUDENTS:Pleasedonotrepeatclasses!

PLACEANUMBERINEACHBOX

☐ Maritime ☐ IndustrialElectricity ☐ CulinaryArts ☐ HeavyDieselTechnology

Checkallthatapply:

☐ IhaveaStateIDCard(Iwillbringit) ☐ IhaveavalidAKDriversPermitorLicense(Iwillbringit)

CheckbelowonlyifyouDONOThaveaStateIDCardorValidAKDriversPermitorLicense:

☐ IhaveaTribalIDCard(Iwillbringit) ☐ IhaveanoriginalSocialSecurityCard(Iwillbringit)

☐ IhaveanoriginalBirthCertificate(Iwillbringit)

THECONFIDENTIALITYOFALLINFORMATIONREQUESTEDINTHISAPPLICATIONISPROTECTEDBYAS23.15.190AND34CFR361.38,ANDCOMPLIESWITH45CFR164.508.

Turn completed application into your principal or counselor.

Ethnicity: White☐ African☐ Hispanic☐ Asian☐ AmericanIndian/AlaskaNative☐NativeHawaiian/PacificIslander☐ TwoorMoreRaces☐



TeacherRecommendationForm

StudentName SchoolDistrict/Site

RecommendingTeacher DatePage1

(1) LimitedEffort (2) Developing (3) Proficient (4) AdvancedCommunication&LifeSkills

☐ Doesnottakeon

personalresponsibilityinmostcases,anddependsonothers.

☐ Hasdifficultyinany

leadershipcapacity.

☐ Actionsshowlackof

communicationskillaswellasalackofunderstandingoftheirimportance.

☐ Demonstrates

personalresponsibilityinconsistently.

☐ Ishesitanttobe

promptedtocompletetasks.

☐ Applies

communicationandetiquetteskillsinsomesettings.

☐ Displayspersonal

responsibilityforsuccessfuldailylivingconsistently.

☐ Critiquesleadership

qualitiesinavarietyofsettings.

☐ Demonstrates

effectivecommunicationandetiquetteinclass.

☐ Encouragesothersin

positivewaystotakeonresponsibility.

☐ Assistsothersin

developmentofleadershipskills.

☐ OffersAssistanceto

otherswithoutbeingasked.

ProblemSolving&DecisionMaking

☐ Experiences

difficultieswhendealingwithchange.

☐ Doesnotrecognize

needforowntimemanagement.

☐ Displayslimited

abilitytodemonstratetimemanagement,problemsolving,decision-making,commitment,follow-throughandworkethicintheclassroomandextra-curricularevents.

☐ Demonstratesan

inabilitytohandlestress.

☐ Practicesflexibility,

adaptability,integrity,andresilienceinconsistently.

☐ Hasdifficultywith

consistencyintimemanagement,problemsolving,decision-making,commitment,followthroughandworkethicintheclassroomandextracurricularevents.

☐ Findsdifficultyin

dealingwithstress.

☐ Demonstrates

flexibility,adaptability,integrity,andresilience.

☐ Practicestime

management,problemsolving,decision-making,commitment,follow-thoughandworkethicintheclassroomandextracurricularevents.

☐ Recognizesstrategies

forstressmanagement.

☐ Activelymodels

flexibility,adaptability,integrity,andresiliencyinwordsandactions.

☐ Displaysand

encouragestimemanagement,problem,problemsolving,decisionmaking,commitment,followthroughandworkethicintheclassroomandextracurriculareventsonaconsistentbasis.

☐ Managesstressand

helpsothers.



TeacherRecommendationForm StudentName SchoolDistrict/SitePage2 (1)LimitedEffort (2)Developing (3)Proficient (4)AdvancedTeamwork ☐ Demandsconstant

proddingtoparticipatewithothers.

☐ Hasdifficultygetting

alongwithothers.

☐ Participatesin

limitedwayswithsomepromptingwhenengagingwithothers.

☐ Hasoccasional

strugglesgettingalongwithothers.

☐ Displaysteamwork

andhealthyrelationshipswhenparticipatingwithothers.

☐ Assistsothersin

need.

☐ Servesasaleaderin

developingteamworkandhealthyrelationshipsinclassandextracurricularactivities.

☐ Fosterscooperation

andaccomplishment.

Goal-Setting ☐ Doesnotrecognize

deadlines.

☐ Rarelysetsown

personalgoals.

☐ Makesandmeets

deadlinesinconsistently.

☐ Displaysdifficultyin

settingpersonalgoalsandcarryingthemthrough.

☐ Makesandmeets

deadlinesonaregularbasis.

☐ Displaystheabilityto

setpersonalgoalsandcarrythemthrough.

☐ Implements

strategiestosetandmeetdeadlinesandgoals,bothindividually,andinclass

Pleasecheckanythatapply(thisinformationwillbekeptconfidential):

Studenthasadisability: ______ StudenthasanIEP:______ Studenthasa504Plan:______TeacherComments:

X

TeacherName(PleasePrint) TeacherSignature

X

PrincipalName(PleasePrint) PrincipalSignature



ParentRecommendationThisinformationgivestheEXCELstaffinsightastotheapplicant’spersonalityandpotential.Pleasehelpuswiththeselectionprocessbyprovidingaccurateandcurrentinformation. StudentName Parent/GuardianNameWhydoyousupportyourchild’sparticipationintheEXCELSummerBridgingCamp? Participationintheprogramwillrequirestudentstoliveawayfromhomefor4weeks.Doyouhaveanyconcernsregardingyourson/daughter’sabilitytohandletheextendedabsencefromhome? Whatextra-curricularactivities(basketball,volleyball,NYO,studentgovernment,etc.)hasyourchildparticipatedin? Doesyourson/daughterhaveanymajormedicalissuesoraddictions(tobacco,drug,and/oralcohol)? Ihaveread,understandanddiscussedtheinformationinthisapplicationwithmyson/daughter.Isupportandagreetohis/herparticipationinallactivities,bothacademicandrecreational,ifmychildisselectedtoparticipate.

X

ParentSignature Date



StudentBehaviorsandExpectationsMustbereviewed,understood,andsignedbyallparticipants.

Youarerepresentativesofandambassadorsforyouschool,teachers,family,community,andself.Youareexpectedtoconductyourselfinaresponsibleandmaturemanneratalltimes.Whatyou“SHOULDNOT”bringtocamp:

Ø Alcohol,controlledsubstancesordrugparaphernalia;Ø Weapons,firearms,knives,oranyobjectthatposesdangertooneselfand/orothers;Ø Tobaccoproducts,includingcigarettes,chew,snuff,iqmik,marijuana,etc.EXCELAlaskadoesnotallowtheuseofany

typeoftobaccoproductbystudentsorstaff.Ourpositionontobaccoistwo-fold:

• UseoftobaccoisindirectoppositiontoEXCELAlaska’sphilosophyofpromotingpersonalwellnessandhealthylifestyles.

• AlaskaStateStatutestatesthatitis“illegaltosell,give,trade,orexchangeanyproducts(includingvendingmachines)containingtobaccotoanypersonunder19yearsofage”.Ifstudentsdocurrentlyusetobaccoproducts,westronglyencouragethemtodiscontinueusepriortoparticipatinginanyEXCELactivity.

• Weunderstandthatmanystudentshaveand/orcurrentlyusetobaccoproductsandweareawareofthesideaffectsassociatedwithwithdrawal.Hardcandyandgumwillbeprovidedtohelpcurbanycravings.

Consequencesforuseorpossessionofalcohol,controlledsubstances,paraphernalia,weaponsortobaccoproductsareasfollows:

Ø Immediatedisciplinaryaction,includingpromptdismissalfromtheprogram;Ø Possiblelegalaction.

PROGRAMRULES

1. Curfewis11:00pm(orasdeterminedbystaff)–lightsout,quiet,inbed.2. Afterlightsout,youarenotallowedtoleaveyourroomuntilbreakfasttime.3. Alwaystravelinpairs(orlargergroups)unlessspecificallygiveninstructionandpermissiontodootherwise.4. Alwaysinformastaffmemberofyourwhereabouts.5. Disrespectingstudents,staff,orthefacilitieswillnotbeallowedandcouldresultindismissalfromtheprogram.6. Nobodypiercing,hairdying,ortattooswhileattendinganyEXCELSessionorCamp–HowyouarriveatEXCELishowyou

willleaveEXCEL!7. NoPDA’s(publicdisplaysofaffection)

IhavereadandunderstandtheaboveexpectationsandagreetoabidebythemduringmystaywithEXCELAlaska.Ialsounderstandwillfulviolationoftheserulesmayresultinmyimmediatedismissalfromtheprogramandexpeditedreturnhomeatmyrespectiveschooldistrict,parentorguardian’sexpense.IalsounderstandthatImaybesubjecttofurtherdisciplineasoutlinedundermyrespectiveschooldistrict’sStudentDecorumCode.

X StudentName(PleasePrint) StudentSignature Date

X ParentName(PleasePrint) ParentSignature Date



MedicalConsentForm StudentName(Pleaseprint) StudentBirthdate Parent/GuardianName(Pleaseprint) Home/CellPhone WorkTelephone InsuranceCompany GroupNumber MedicaidNumber EmergencyContactName Home/CellPhone WorkTelephonePleaseanswerthefollowingquestions: YES NO Specify

1. Doesyourchildhaveanyallergies? ☐ ☐

2. Doesyourchildhaveaheartmurmur? ☐ ☐

3. Doesyourchildhaverheumaticheartdisease ☐ ☐

4. HasyourchildeverhadT.B.? ☐ ☐

Isthereanythingelseweshouldknowaboutyourchild’shealth? ☐ ☐ I,parent/legalguardianof ,giveconsenttoemergencymedicaltreatment,hospitalization,ormedicaltreatmentasmaybenecessaryforthewelfareofmychildifhe/sheissickorinjured.He/shemaybetreatedbyamedicalprovider.Iherebywaiveonbehalfofmyself,andtheabovenamedchild,anyliabilityofEXCELAlaskaorKuspukSchoolDistrict,oranyofitsagentsoremployees,arisingoutofsuchmedicaltreatment.IUNDERSTANDTHATEVERYEFFORTWILLBEMADETOCONTACTME.IFICANNOTBEREACHED,IHEREBYGIVEEXCELALASKASTAFFTHEPERMISSIONTOACTONMYBEHALFINSEEKINGEMERGENCYTREAMENTFORMYCHILDINTHEEVENTREATMENTISDEEMEDNECESSARY.INADDITION,IGIVEPERMISSIONTOTHOSEADMINISTERINGEMERGENCYTREATMENTTODOSO,USINGTHOSEMEASURESDEEMNECESSARY.IABSOLVEEXCELALASKA,INC.,KUSPUKSCHOOLDISTRICTANDITSASSOCIATESFROMLIABILITYINACTINGONMYBEHALFINTHISREGARD.EXCELAlaska,Inc.,KuspukSchoolDistrict,andtheirassociatesarenotresponsibleformedicaltreatmentdeductiblesorresponsibleforpaymentoffinancialbillingsofmedicaltreatmentreceivedatanytime.

X SignatureofParent/Guardian Date



MediaConsentFormDearStudentsandParents/Guardians,Wemayberecording(audio,video,anddigitalstills)teacherandstudentactivitiesassociatedEXCELAlaska,Inc.including,butnotlimitedtoEXCELsessions,intensives,andcamps.Theserecordingsmaybeusedforeducationalandinformationaluseinavarietyofmediarangingfromourwebsite,Facebook,andEXCELnewsletterstoEXCELAlaskapromotionalvideos.AllrecordedmaterialisthepropertyofEXCELAlaska,Inc.Pleasereadthefollowingguidelinesandcheckthecorrespondingboxifyouagree/disagree:

1. Igivepermissionformyson/daughtertoparticipateinanyvideo/taperecordingandphotographythatmaybecomepartofmaterialsorproductsthatcouldbesharedwithschooldistrictandbusinesspartners.

2. Iunderstandtheintentionoftherecordings/photosandthepurposeoftheprograms,asstateabove.

☐ Iagreetotheguidelineslistedaboveandgivepermissionformychildtoparticipateinanymediarecordings/photos associatedwithorobtainedbyEXCELAlaska,Inc.

☐ Idisagreewiththeguidelineslistedaboveanddonotgivepermissionformychildtoparticipateinanymedia recordings/photosassociatedwithorobtainedbyEXCELAlaska,Inc.

X StudentName(PleasePrint) StudentSignature Date SchoolName/Location SchoolDistrictName~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

X ParentName(PleasePrint) ParentSignature Date Address City State ZipCode



VisitationPermissionFormON-CAMPUSVISITSONLYDURINGSCHEDULEDVISITATIONHOURSScheduledon-campusvisitationoccursdaily(timeTBD)SundaythroughThursday.Allvisitorsmust:

ü Signinandbeonthestudent’svisitationpermissionform;ü Showidentification;ü StaywithinthesetEXCELCampboundaries(campusboundaries);ü Notgointodormroomsorprivateplaces.

WEEKENDCHECK-OUTSARELIMITEDTOFAMILYMEMBERS(21YEARSOROLDER)ONLYWeekendcheckoutsmaystartat5:00pmonFriday.Studentsmustarriveandbesignedbackontocampusby5:00pmonSunday.Inordertobecheckedoutthevisitormust:

ü BelistedontheVisitationPermissionFormasOKforweekendcheck-outs;ü Beamother,father,guardian,brother,sister,aunt,oruncle;ü Be21yearsofageorolder;ü Thecheckingthestudentoutmustbephysicallypresentinordertocompletethecheckout;ü Showpictureidentification(AlaskaDriver’sLicense,StateID)

PARENT/GUARDIANAGREEMENT:I, ,herebygivepermissionforthefollowingadults,21yearsorolder,to PrintParent/LegalGuardianNamevisitmyson/daughter duringEXCELSummerBridgingCamp. PrintStudent’sNameIhavereadtheEXCELVisitationPolicyandsupportthisprocessforallowingourfriendsand/orfamilytovisitmychildduringtheprogram.

X SignatureofParent/Guardian Date~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ STUDENTAGREEMENT:I, ,agreeandwouldlikethefollowingfriendsandfamilymemberstovisitwith PrintStudent’sNamemethissummerwhileIattendSummerXLCamp.Ihavereadthevisitationpolicyandagreetoabidebythispolicyduringtheentiretyofthecamp.

X SignatureofStudent DateFRIEND/FAMILYNAME OnCampusVisitation WeekendCheckout1. YES/ NO YES/ NO2. YES/ NO YES/ NO3. YES/ NO YES/ NO4. YES/ NO YES/ NO5. YES/ NO YES/ NO

summer xl student application - kuspuk.org xl... · © 2017 – 7excel alaska, inc. media consent...

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