Georgia Migrant Education Program Leadership Academy at ABAC

Transcription

1 Georgia Migrant Education Program Leadership Academy at ABAC The Georgia Migrant Education Leadership Academy invite participants to its summer leadership academy held at Abraham Baldwin Agricultural College (ABAC). The two week residential program will expose participants to campus life at ABAC through extracurricular activities and academic classes with ABAC faculty and staff in an effort to convey the importance of a high school diploma and a post-secondary education. The program is also designed to encourage migrant students to become more involved in academic subjects such as Language Arts Mathematics, and Science in order to have a successful post-secondary education. Dates: June 1-13, 2014 Audience: Current eligible migrant education high school students, rising 9 th, 10 th, 11 th, and 12 th graders. Cost: Free Classes Offered: Writing Language Arts/Reading Mathematics Science/Social Studies Study Skills Career awareness Extracurricular Activities: Team Building Exercises Motivational Workshops Educational Outings Cultural/Social Activities Requirements: Current eligible migrant student (Priority will be given to PFS students) Copy of the latest report card and Certificate of Eligibility (COE) Rising 9 th, 10 th, 11 th and/or 12 th graders Complete application and return by April 1, 2014 Applications are due to your regional Migrant Education Program office by April 1, 2014.

2 Georgia Migrant Education Program Leadership Academy at ABAC June 1, June 13, 2014 STUDENT INFORMATION: (Please use blue/black ink pen ONLY) Name: First Middle Last County: Date of Birth: Sex: M / F Age: Grade: Father: Mother: Mailing Address: City: State: Zip: Telephone Number: Emergency Contact: Home Work Cell Name Address Telephone Number ****Have you ever participated in this summer leadership? Yes No**** List extracurricular/leadership involvement: clubs, awards, recognitions, sports, interest areas, etc: Completed by High School Migrant Staff: Applications will be returned if this section is not complete Attach copy of Report Card PFS: YES / NO Attach copy of Friendly COE Regular Attendance: YES /NO QAD: Disciplinary Problems: YES / NO Priority For Services: Section 1304(d) of the Statute gives priority for services to migrant children: (1) who are failing, or most at risk of failing, to meet the State s challenging State academic content standards and challenging state student academic achievement standards, and (2) whose education has been interrupted during the school year

3 PARENTAL/GUARDIAN STATEMENT If selected, I give permission for to participate in the Georgia Migrant Education Leadership Academy sponsored by the Georgia Department of Education. I understand that as a part of this workshop, will take part in several different activities which include: 1. Academic classes 2. Physical activities 3. Career information 4. Study skills 5. Test taking tips 6. Exposure to different cultures and social interactions Please list any allergies, health, or dietary restrictions that affect your child. Include a list of any medications your child is currently taking. I hereby waive and release any and all rights and claims of damages which I may incur against the Migrant Education Program, personnel of the Migrant Education Programs, ABAC and personnel of ABAC, for any and all injuries which my child may suffer as a result of participating in this workshop. I attest and verify that I have full knowledge of the risks involved in this event. Parent/Legal Guardian Signature Date ** NOTE ** Parents/legal guardians are responsible for taking their child(ren) to ABAC campus on registration day and picking them up after graduation. The Georgia Department of Education employees will not provide transportation to or from the ABAC campus.

4 DECLARACIÓN Para Padres / Tutores Legales Si resulta seleccionado/a, autorizo a para participar en la Academia de Liderazgo del Programa de Educación Migrante de Georgia patrocinado por el Departamento de Educación de Georgia. Entiendo que como parte de este programa, tomará parte en diversas actividades que incluyen: 1. Clases académicas 2. Actividades físicas 3. Información profesional de carreras 4. Técnicas de estudio 5. Estrategias para tomar exámenes 6. La exposición a diferentes culturas e interacciones sociales Por favor anote cualquier alergia de salud, o restricciones en la dieta que afectan a su hijo/a. Incluya una lista de los medicamentos que su hijo/a está tomando actualmente. Yo renuncio a todos los derechos y reclamaciones de daños que pueda incurrir en contra del Programa de Educación Migrante, el personal del Programa de Educación Migrante, ABAC y el personal de ABAC, por cualquier lesión y todo lo que mi hijo/a puede sufrir como resultado de participante en este taller. Doy testimonio y verifico que tengo pleno conocimiento de los riesgos involucrados en este evento. Firma de Padre(s) / Tutor Legal Fecha ** NOTA ** Los padres / tutores legales son responsables de llevar a su hijo/a(s) al colegio de ABAC en el día de registración y recogerlos después de la graduación. Los trabajadores del Programa de Educación Migrante del Departamento de Georgia no proveerán transportación de o hacia al colegio de ABAC.

5 RECOMMENDATION FORM Student s Name STUDENT: Please take this form to a teacher, counselor, or school administrator who knows you. Ask this person to complete the form. Name of Evaluator: Position: School: Phone # Address: City: State: Zip: TO THE EVALUATOR The named student is applying for the Georgia Migrant Leadership Academy at Abraham Baldwin Agriculture College. Please comment on his/her academic standing and how participation in this project would benefit his/her continuing improvement and academic growth. Thank you for your assistance. How long have you known this student? In what capacity? Comments: Signature Date

6 Summer Programs and Camps HEALTH HISTORY AND CONSENT FORM As required under University System Policy, this form must be completed and returned to Abraham Baldwin College before the student will be eligible for Program enrollment. PART A To be completed by the parent or guardian for the participant (Please Print) Expected date of Name Program enrollment Last First Middle/Maiden Semester/Year Home Address City, State, Zip Sex: Male Female Date of Birth Telephone ( ) Social Security Number Home Physician City, State Physician s Telephone Number PART C Directions: Please complete this portion of the form completely and carefully. It is not necessary to consult a physician for this history. Answer all questions. Information supplied will become part of a Health Record at ABAC. It will be held in the strictest of confidence. FAMILY HISTORY Father: Living Dead If so, cause of death: Mother: Living Dead If so, cause of death: Brothers & Sisters: Number If any have died, cause(s) of death(s): Have any of your relatives had any of the following (check appropriate box) Diabetes Tuberculosis Cancer Kidney disease Heart disease/high blood pressure HAVE YOU EVER HAD or do you now have any of the following (check appropriate box): Shortness of breath Chicken Pox Scarlet Fever Head injury Recurrent back pain Jaundice Tuberculosis Rheumatic fever Arthritis Diabetes Mellitus Chronic cough Bleeding/Hemophilia Hay fever Asthma Epilepsy or convulsions Periods of unconsciousness Ear, nose or throat trouble Stomach, liver or intestinal trouble Paralysis or weakness Kidney stones or blood in urine Infectious mononucleosis High or low blood pressure Measles Rubella (German Measles) Other, please specify: Have you received treatment or counseling for emotional problems within 5 years? Yes No (If yes, attach explanation) Do you know any reason why you should not participate in physical activities? Yes No (If yes, attach explanation) Has your physical activity been restricted during the past 5 years? Yes No (If yes, attach explanation) Have you ever had an allergic reaction to the following (check only appropriate boxes, if any): Penicillin Sulfa Eggs or Chicken Bee Stings Other, please specify: Do you take any medication on a regular basis prescribed by your physician? Yes No (If yes, list below) Name of Drug Dosage Frequency If you are under 18 years of age, your parent or legal guardian must sign below in the space designated. If you are 18 or older, your signature alone will suffice. I hereby authorize the ABAC Student Health Center, its agents or consultants, to perform diagnostic and treatment procedures on the program participant named above. I waive all claims to prior notification. If, in the judgment of the professional staff, the student s parents or guardians should be notified, this will be done. SIGNATURES Student (if 18 year or older) Date Parent/Guardians 1. _ Date 2. _ Date Allergies: PERSONS TO NOTIFY IN EMERGENCY: List below persons who may be notified in the event of an emergency. 1. Name Relationship Address Telephone ( ) 2. Name Relationship Address Telephone ( )

7 GEORGIA DEPARTMENT OF EDUCATION STATE OF GEORGIA COUNTY OF FULTON RELEASE FORM FOR MINORS Participant s Name: ( Participant ) Program Title: GA Migrant Education Program Leadership Academy at ABAC Production Date(s): June 1, 2014 to June 13, 2014 ( Program ) 1. In consideration for the opportunity of the Participant identified above to participate in the Program identified above, I grant to the Georgia Department of Education ( GaDOE ), the producer and owner of the Program: 1. The right to photograph, record, and otherwise reproduce the Participant s image, voice, and/or likeness in connection with the Program in perpetuity; 2. All rights of use, ownership, and copyright in such photographs, recordings, and reproductions; 3. The right to distribute such photographs, recordings, and reproductions without limitation by any means; and 4. The right to use such photographs, recordings, and reproductions and, if necessary, the Participant s name and biographical information to promote the Program. 2. I understand that neither I, nor the Participant, will be compensated monetarily or otherwise. 3. I release GaDOE, its employees, and assigns, and the local school system and its employees, and assigns from all liability for any claims by me, the Participant, or any other person arising in connection with the Program. 4. I agree to indemnify and hold harmless GaDOE for and against all claims by the Participant arising in connection with the Program or this Release, and for all costs or damages resulting from the Participant s disaffirmance of this Release. 5. I certify that I am the parent of the Participant or am otherwise legally authorized to grant this release. DATE: TELEPHONE: SIGNATURE PRINT NAME RELATIONSHIP to PARTICIPANT STREET ADDRESS CITY, STATE, ZIP

8 GA Migrant Education Program Leadership Academy *********Students please keep this page at home*********** Dates: June 1-13, 2014 ITEMS FURNISHED: 1. All classroom materials 2. Meals and snacks 3. Sheets, blankets, pillow, pillowcase, towels, and washcloths ITEMS YOU WILL NEED TO BRING: 1. Appropriate regular school clothing. You will be able to wash clothes once after the first week while you are on campus. You will need appropriate clothing and footwear to wear for our graduation ceremony on the last day. (Jeans and/or shorts WILL NOT be permitted during graduation ceremony.) 2. Shoes tennis shoes plus one pair of street shoes, if possible. 3. Appropriate bathing suit / swim shorts. (If schedule allows it) 4. A thin jacket/ or long sleeve shirt (We are not able to change temperature in classrooms) 5. A small amount of money for personal use. 6. Personal care items. (toothbrush, tooth paste, hair brush, lotion, etc ) DO NOT BRING: 1. ipods, ipads, or tablets 2. Cell phones 3. Jewelry or items that can be easily stolen ** NOTE ** Parents/legal guardians are responsible for taking their child(ren) to ABAC campus on registration day and picking them up after graduation. The Georgia Department of Education employees will not provide transportation to or from the ABAC campus. Contact emergency phone numbers for the duration of the leadership academy will be given to parents and staff on the day of registration.