asb application

7/27/2019 ASB Application

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Emergency/Health Information

Contact Information

General Information

Alternative Spring Break

Application

Name: USC ID:

Date of Birth: _____/____/_____ Age:

Class Standing (circle one):Freshman Sophomore Junior Senior Graduate Young Professional Other

Major(s): Minor(s):

Do you speak another language? If so what language? (there is no language requirement)

Email Address:

Phone (Best number to reach you):

Emergency Contact : Relationship:

Address:

Phone (home): Phone (cell):

Please list any medications currently being taken:

Please list any allergies (medications and non-medications):

Please list any health (including physical) concerns and/or special dietary needs:

Insurance Provider: Phone:

Primary Insured: Policy #:

Turn in Application to the Catholic Center by6PM on Thursday, October 17th, 2013

Only completed and signed applications will be accepted.



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Turn in Application to the Catholic Center by6PM on Thursday, October 17th, 2013


Additional Information

How did you find out about our trips:Website Friend Poster/Flyer CC Staff Information Session

Other____________________________________________________________

If 21, are you willing to drive a rental vehicle Yes No

Do you know First Aid? Yes No

Are you CPR certified? Yes No

Have you participated in an ASB with the Catholic Center before? Yes NoIf so, which trip and when?______________________________________________

____________________________________________________________________ ____________________________________________________________________

Have you participated in an ASB with USC before? Yes NoIf so, where did you go?_________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Are you willing to take on extra responsiblities (i.e. creating group social events, being a teamcaptain during the actual trip) as a trip program coordinator?

Yes No

Is this your last chance to go on a ASB trip? Yes No

Our Goal is to select a team composed of:50/50 male/female mix

Mix of grade levelsWe will take into consideration if it is your last chance to go on the trip

Priority will be given to current USC Students &Students Registered at the USC Caruso Catholic Center



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Las Marias, Puerto Rico

We can take up to 12 people including 1 staff member on this trip.We are working with Plenitude Inicitivas Eco-educativas http://www.plenitudpr.org/Total Cost: $1,500 total per student. Cost includes food, shelter, and all transportation.

Cost per student: $1,000 for Las Marias, Puerto Rico trip.

Type of service: Some examples of service activities include: developing and improving the infrastruc-ture a tour teaching center (road maintenance, painting, fence-building, etc.); working with food produc-tion (work in the green house, weeding and planting garden beds, clearing new areas for planting, har-vesting and washing crops, etc.); working with natural building projects (natural plastering, buildingwith alternative building techniques such as super adobe and rammed earth); and community outreach projects (community gardens, school gardens, and misc. agricultural projects).

El Paso, Texas

We can take up to 12 people including 1 staff member on this trip.

We are working with Annunciation House, http://www.annunciationhouse.org/

Total Cost: $1,000 total per student. Cost includes food, shelter, and all transportation.Cost per student: $700 for the El Paso, Texas trip.

Type of service: The objective of the Border Awareness Experience (BAE) is to facilitate face to facemeetings and encounters between BAE participants and people and groups on both sides of the Border.It intends to raise consciousness in the ‘first world’ about the issues facing the peoples of the ‘thirdworld’ and the effects of unjust economic policies on their lives. It is an opportunity to listen to different perspectives and opinions about issues such as immigration, economic development, human rights, andsocial justice. It seeks put a face on the immigrant, the factory worker, the refugee, and the Border Pa-trol Agent. Some typical service activities include cleaning the house - kitchen, grease trap, bathrooms,dorm rooms - where the immigrants live, doing laundry, and sorting and organizing food and clothing pantries.

San Juan Bautista, California

We can take up to 12 people including 1 staff member on this trip.We are working with Community Links International http://commlinksorg.drupalgardens.com

Total Cost: $900 total per student. Cost includes food, shelter, and all transportation.

Cost per student: $600 for the San Juan Bautista, California trip.

Type of service: Can include environmental service such as organic composting and gardening,reforestation, recycling, greenhouses, composting latrines, solar ovens, litter campaigns, etc;Community-Based Education - with children, youth and their families focusing on environmentalissues; and catalyzing fair trade opportunities for local producers.

The financial difference will be made in fundraising. Students selected to go on this trip mustcontribute to all of the fundraising activities of the Catholic Center for ASB.

Turn in Application to the Catholic Center by6PM on Thurs. October 17th, 2013.


http://commlinksorg.drupalgardens.com/





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Please Read This Thoroughly!

Before reading, keep in mind that this is a Catholic service trip. This trip is intended to follow

Catholic values of social justice. Initialing next to each one, and sign the bottom portion of the sheet.Your signature at the bottom signifies you will abide by these rules.

General Guidelines:

___ I understand the Catholic center promotes an alcohol/drug free policy on ALL ASBtrips for all participants regardless of their age. This trip will be a dry and chaste trip(i.e. no alcohol, drugs, or sexual activity will be tolerated in any way at any point intime for the duration of the trip).

___ I understand that I could be sent home at my own expense if I violate the alcohol/drug policy.

___ I agree that any image taken of me while on any trip or during ASB related events maybe used for Catholic Center promotional material.

___ This trip will include interactions with the local community. Therefore, you areexpected to go on this trip with a respect for other cultures.

___ The service project we are participating in requires physical labor. Anyone is welcometo participate despite any physical ailments, provided that we are informed ahead of time. Also, any level of physical ability is greatly appreciated and should notdiscourage anyone from applying.

___ Please check with your doctor or the University Health Center for the appropriateinoculations (i.e. shots) before travelling to Puerto Rico, El Paso and/or San JuanBautista.

___ You are responsible for the proper documentation (i.e. drivers license or state issued ID,

travelling health insurance, signed liability waiver - see attached form.) ___ For safety and security reasons, everyone is to stay with the group unless explicitly said

otherwise by a coordinator. If this rule is violated, I understand that I could be senthome at my own expense.

Involvement, I will:

___ participate in the entire trip. I understand that I may not arrive late or leave early andthat the Catholic Center cannot accommodate individual travel requests.

___ attend ALL pre-trip orientation meetings. ___ participate in ALL activities during the trip, including the volunteer service, meals,

meetings, and reflection sessions. ___ participate in ALL fundraising projects. ___ fundraise with the group and individually in order to cover the remainder of the costs. ___ respond in a timely manner (within 96 hours) to communications from the ASB trip

coordinators. I acknowledge that I could potentially forfeit my spot on the ASB trip if Ifail to meet this expectation.

Turn in Application to the Catholic Center by6PM on Thursday, October 17th, 2013.




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Payments, I will/I understand:

___ pay a NON-REFUNDABLE deposit of $350 for Puerto Rico and $300 for El Paso and/or San Juan Bautista that will secure a spot on my trip. This fee will also be deductedfrom the overall cost of my trip.

___ payment schedule is as follows:Puerto Rico El Paso, TX San Juan Batista, CA

1st payment (deposit) 10/24, 6pm $350 $300 $200 2nd payment 11/14, 6pm $350 $200 $200 3rd payment 1/23, 6pm $300 $200 $200 Total w/deposit $1,000 $700 $600

___ if the NON-REFUNDABLE deposit is not turned in by the payment date, 10/24,at 6pm, I forfeit my spot to the next person on the waitlist.

___ my participant fee includes will help cover food, lodging, group cultural activities, andtravel fees, as specified by my ASB coordinators. The fee does NOT include: baggagefees for air travel trips, travel Insurance, or extras such as snacks.

___ my participant fee will not be partially refunded to me for any aspects of the trip inwhich I do not participate.

Withdrawal, I will/I understand:

___ if I withdraw from the ASB trip after January 23rd, 2014 I understand that I will still beresponsible for paying the remaining balance of the total cost of the trip. NO EXCEPTIONS.

I understand the time and commitment my participation on al alternative spring break entails,and agree to abide by all of the guidelines listed above.

_________________________ _________________________ Student Name (print) Student Signature

_________________________ _________________________ Trip Date

Turn in Application to the Catholic Center by6PM on Thursday, October 17th, 2013.




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RELEASE OF LIABILITY

This release is in consideration of my being permitted to participate in the following

Event scheduled for ________________________________________________________:(insert date(s))

__________________________________________________________________________.(insert name/description of Event)

I recognize there are risks of injury, sickness, loss and other costs and expenses associated with participating in this Event. I hereby agree to assume all risks that may occur as a result of participating in this Event. I hereby release the University of Southern California (“USC”) and

__________________________________________________________________________ (insert name of student club)

and their respective officers, directors, trustees, employees, faculty, administrators, members,

agents and representatives, as applicable, from any and all claims, causes of action, losses,liabilities, costs, and expenses (including reasonable attorneys’ fees), arising or resulting fromor in connection with my participation in the Event, including as a result of their negligence, if any. If I am injured, I agree to assume any financial obligation, either through my healthinsurance, or through some other means, for any medical costs which I incur. USC and/or theothers released herein assume no responsibility for any medical expenses, injury, or damagesuffered by me in connection with the Event.

This release shall be construed in accordance with, and governed by, the laws of the State of California.

I acknowledge that this release is a complete release of liability given in consideration for being permitted to participate in the Event, and that I have read this release and understand its mean-ing and effect. I further agree that my assignees, heirs, parents, guardians, and legalrepresentatives will not make any claim against, sue or attach the property of USC and/or theothers released herein for any loss or damage resulting from my participation in the Event. I

am aware of the potential dangers incidental to participating in the Event, that this is a

release of liability, a waiver of my legal right to collect damages in the event of injury,

death or property damage, and a contract between me and those released herein, and I

sign it of my own free will.

Date: Signed: ___________________________________

Please PRINT name here: ____________________________________________________ IF PERSON SIGNING RELEASE IS UNDER EIGHTEEN, PARENT/GUARDIANSIGNATURE IS REQUIRED BELOW:

Parent/Guardian Signature: _______________________________ Date: _______________

Print Name of Parent/Guardian: __________________________________________ USC File 10.1.2012



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Short Answer Questions

The responses to the following questions will help us tailor the formation of the trip to everyone’s needs.

There are no right or wrong answers. Please answer all of the questions below.

1. Which service trip is your first preference, Puerto Rico, El Paso or San Juan Bautista, CA? Why doyou want to go on this particular trip? If you are selected to go on the trip that is not your first preference would you still like to attend?

2. What does social justice mean to you?

3. What do you expect to learn/gain out of this trip?

4. What will you contribute to ASB? What unique skills, knowledge or qualities do you have that willenhance the group?

5. Have you ever been on a service trip (local or abroad) before? If so, describe the trip and your overallexperience.

6. Describe your understanding of the social teachings of the Catholic Church?

7. Tell us a fun fact about yourself.



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Checklist

To give us (this information is due on 1/23/14 unless otherwise indicated):

Copy of government issued idCopy of USC ID Card ______ Signed USC Waiver, Release and Indemnity Agreement - DUE 11/14/13 ______ Signed Archdiocese of Los Angeles Release Form - DUE 11/14/13

Filled out and signed application - DUE 11/14/13Proof of insurance

What to bring:ToiletriesSturdy work shoesSleeping bagPillow (or you can use a sweatshirt to save space)Climate appropriate clothing

Happy attitudeMoney for extra expenses(souvenirs and extra food not covered by the Social Justice Committee)

What not to bring:

Guns, alcohol, sharp objects, aerosols (please follow TSA regulations)Bad mojoExpensive belongings

Deadlines (make sure to keep track of these): 10/17/13 Application Due 10/24/13 First Payment Due

10/28/13 1st Meeting for El Paso & San Juan Batista (6pm-7pm)

10/31/13 1st Meeting for Puerto Rico (6pm-7pm)

11/14/13 Second Payment & ALL Paperwork Due

11/18/13 2nd Meeting for El Paso & San Juan Batista (6pm-7pm)

11/21/13 2nd Meeting for Puerto Rico (6pm-7pm)

1/23/14 Third Payment Due

1/27/14 3rd Meeting for El Paso & San Juan Batista (6pm-7pm)

1/30/14 3rd Meeting for Puerto Rico (6pm-7pm)

2/10/14 4th Meeting for El Paso & San Juan Batista (6pm-7pm)

2/20/14 4th Meeting for Puerto Rico (6pm-7pm)

3/10/14 5th Meeting for El Paso & San Juan Batista (6pm-7pm)

3/13/14 5th Meeting for Puerto Rico (6pm-7pm)

3/15/14 - 3/22/14 Spring Break Trips to Puerto Rico, El Paso, and San Juan Batista.

Social Justice Contact Information:

Mayra Moran, Alternative Spring Break Coordinator

(714) 883-3723

[email protected]

Rosie Chinea Shawver, Campus Minister

(310) 963-9783

[email protected]

Jamie Zamora, Social Justice Chair

(951) 733-8283

[email protected]

asb application

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