to be eligible for this program a student...

2015 NSORO Precollegiate Program Application

University of AlabamaJune 14-19, 2015

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TO BE ELIGIBLE FOR THIS PROGRAM A STUDENT MUST: Be in foster care, a ward of the state or emancipated. Be a rising 10th-11th grader in the 2014-2015 school year. Demonstrate a commitment to graduate from high school, have a desire to go to a college

or University, and become a contributing member of society. Commit to participate in all NSORO Precollegiate Program sessions.

APPLICATION INSTRUCTIONS Please complete the following form in neatly printed blue or black ink. Use the official application form or photocopy the form. Answer all questions. Confine your responses to the space provided. Check for correct grammar, spelling and punctuation. Applicants will also need to include a copy of an informal transcript and/or a copy of the

most recent report card. These can be requested through your school counselor.

PERSONAL INFORMATION1.) First name: Last name: Preferred name for name tag: 2.) Birth date: 3.) Address:

4). County of Residence:5.) Phone:________________________2nd Phone: ___________________________6.) Email:____________________________2nd email:____________________________7.) Grade in Fall 2014:______________________________________________8.) T-shirt size: S M L XL9.) Gender: M F10.) List any food allergies:_______________________________________________________________________________________________________________________________________

SOCIAL WORKER INFORMATION1.) Name: 2.) Phone: 3.) Email: 4.) County of Employment:



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EDUCATIONAL GOALS1.) If you have thought about continuing your education, list the institutions where you would like to enroll, list them in order of preference:

1.) Institution: City, ST:



Desired career:

COMMUNITY SERVICE / VOLUNTEER ACTIVITIES / EMPLOYMENT1.) List any service activities in which you have participated, beginning with the most recent (this can range from babysitting a younger sibling to being the president of a club). Only list one activity per line. If the list exceeds the allotted space, feel free to attach an extra sheet.If none, please use space provided to explain why you’ve been unable to volunteer.

Activity/organizations Your role From/to Hours per week(Avoid abbreviating) (Position(s) held) (mm/yy)

2.) Do you work during the school year? Yes No Where?

Supervisor’s name:

Email:

What are your primary duties?

Title:

Phone:



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RECOMMENDER FORMThis form (attached) must be completed by an instructor or advisor. Write your name in the name area at the top, and then give it to your recommender with at least two weeks to complete the form. Ask the recommender to return the Recommendation Form to you in a sealed envelope with his or her signature written across the seal. Leave it sealed, and submit the sealed recommender form with your application by the deadline. You should pick a recommender who can address the following items:

a. Academic record, plans, and goalsb. Personal strengths: including motivation, leadership, and commitmentc. Community service and extracurricular activities

REQUIRED APPLICANT CERTIFICATION AND RELEASE INFORMATIONApplication must read and sign below to be eligible:

I certify that all information on this application is true and complete to the best of my knowledge.

I certify that I meet all eligibility requirements as specified on this application. I hereby authorize UA to share my application for the purpose of evaluation, recruitment,

public relations, possible scholarship and internship opportunities, or any other related activity.

I understand that I must notify UA of any change in my address or contact information.

Applicant’s name:

Signature: Date:

Legal Guardian’s name:

Signature: Date:

APPLICATION CHECKLIST (items to be submitted) Application Recommender Form (in sealed, signed envelope) Latest Report Card or Academic Transcript Completed Prescription form (If applicable)

Mail application package by postmark priority deadline May 1, 2015 and final deadline June 1, 2015to: 2015 NSORO Precollegiate

ProgramAttn: Jameka Hartley

University of Alabama801 University Blvd, Room 254; Box 870114

Tuscaloosa, Alabama, 35487



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Recommendation Form

Applicant Name:

The person named above is applying to the NSORO Precollegiate Program at the University of Alabama. This evaluation is a critical component of our decision.Please complete both parts of this form and return it signed to the student in a sealed envelope with your signature written across the seal. The student must submit all application materials by the postmark priority deadline: May 1, 2015 and final deadline June 1, 2015.

NOTE: If the recommender is initiating the application for a student, state why you think this student merits consideration for the NSORO Precollegiate Program.

PART 1: RECOMMENDER INFORMATION

1.) Name: Professional Title:

2.) Institution/Company:

3.) Address:

4.) Phone:

5.) Primary Email:

6.) How do you know the applicant?

2nd Phone/Fax:

7.) How long have you known him/her? <1 yr ≈1 yr <2 yrs 2+ yrs

8.) How well do you know him/her? Casually Fairly Well Well Very Well



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PART 2: WRITTEN EVALUATIONIn the space below or in an attached letter, please describe specific instances of abilities, skills, and attributes, and include any limitations as well as strengths for the following areas:

Academic habits (e.g., challenges oneself, manages time well, utilizes academic support networks)

Leadership (e.g., ability to lead and motivate others) Motivation and long-term goal setting (e.g., sets realistic goals & develops strategies for

completing these goals) Self-awareness / self-concept (e.g., understanding of personal strengths and weaknesses) Community involvement (e.g., family, school, community, or extracurricular activities)

Recommender’s Signature: Date:



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The University of AlabamaAlabama REACH

RELEASE AND AGREEMENT FOR TELEVISION/RADIO IMAGES

The subject hereby gives The Board of Trustees of The University Alabama and its Alabama REACH program, the absolute, perpetual, and worldwide right and permission to use the following described photographs, paintings, or other images, some or all of which may include my likeness:

Video images recorded during June 14-19, 2015 NSORO College Bound Pre-Collegiate program

Without in any way limiting such right and permission, I acknowledge that such photographs, paintings, or images, or any part of the photographs, paintings or images may be used in combination with or as a composite of other matter, such as text, data, graphics, illustrations, and video and audio segments. Distribution may include, but is not limited to, television broadcast, theatrical or closed circuit exhibition, reproduction on videocassettes and DVD for schools, libraries, internet, and home viewers.

I acknowledge that The Board of Trustees, through its Alabama REACH program, is the owner and copyright holder of the program in which the above described photographs may be used. Nothing contained herein shall in any way obligate any party to utilize the described photographs.

I hereby release and discharge The Board of Trustees of the University of Alabama, its officers, agents, and employees, from any claim, demand, or cause of action, whether known or unknown, for defamation, invasion of privacy, or similar matter based upon or relating to the use and exploitation of the described photographs.

I represent and warrant that I possess all rights necessary for the grant of this license, and will indemnify and hold the Alabama REACH program, its licensees and assigns, harmless from and against any and all claims, damages, liabilities, costs and expenses arising out of a breach of the foregoing warranty. Subject agrees that the Alabama REACH program shall have the unlimited right to vary, change, alter, modify, add to and/or delete from his depiction in the photographs, paintings, or other images, and to rearrange and/or transpose his depiction, and to use a portion or portions of his depiction or character together with any other literary, dramatic or other material of any kind.

Printed Name ___________________________________________________

Signature ______________________________________________________(Parent signature if under 18)

Address _______________________________________________________

______________________________________________________________

Date __________________________ Phone ________________________



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The University of Alabama

2015 NSORO College Bound Pre-collegiate Program Prescription Form

This form must be completed in full prior to arriving at The University of Alabama.

All prescription medications, including medications for conditions such as food, drug or insect allergies; diabetes; asthma; or epilepsy may be brought to Program under the condition that the student can self-manage care and delivery of medication with written authorization to do so at the program by a licensed health care provider. Prescription medication must be in its original container labeled by the pharmacist or prescriber. Label must include the name, address and phone number for pharmacist or prescriber. Containers must hold only the amount required for the time the student will be attending the Program.

PRESCRIBER AUTHORIZATION FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION

Medication Name:____________________________________________ Dose: ___________________________________

Condition for which medication is being administered: _________________________________________________________

Specific Directions (e.g., on empty stomach/with water, etc.):__________________________________________________

Time/frequency of administration: ______________________________________________________________________

If PRN, frequency:____________________________________________________________________________________

If PRN, for what symptoms: _____________________________________________________________________________

Relevant side effects: ______________________________________________________________________________

Medication shall be administered from (date)_______________________ to ______________________________________

Special Storage Requirements: ______________________________________________________________________

Is the student capable of self-managed care? YES NO

Prescriber’s Name/Title: _______________________________________________________________________________

Prescriber’s Place of Employment: _________________________________________________________________

Telephone: ______________________________________Fax: __________________________________________________

I hereby affirm that this individual has been instructed in the proper self-administration of the prescribed medication(s).

Prescriber’s Signature:___________________________________________ Date: _______________________________

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