2015 Summer School Forms Packet
Checklist & Forms *We strongly urge having this checklist on your refrigerator* Checklist of To Do’s & Important Forms Return Tuition Payment Form (page 18) and applicable payment. Return Parental Permission Form (page 16). Make an appointment with your child’s pediatrician. Make travel arrangements with airline, train, bus, etc. within approved dates and times (please refer to “Campus-‐Specific Information” on page 25). Return Summer Transportation Form (page 23), including any over-‐ night and shuttle request information. Return Medical Information Form (pages 19 and 20) with a copy of both sides of your Medical Insurance ID Card. Return Physician’s Signature Form (page 21). Pay tuition balance. Submit Course Change Request Form (page 24) -‐ optional. Submit Roommate Request Form (page 22) -‐ optional. Internet Fee (Except for Princeton. Refer to “Campus-‐Specific Information” (page 25) for rates; a blank check made.) Room Key Deposit(s) (refer to “Campus-‐Specific Information” for rates; a blank check made out to “JSA” works best). Authorization to visit/take student off campus -‐ optional. Make arrangements for rental computer (strongly suggested if you do not have your own computer). Congressional Workshop Forms and Assignment (this will be emailed to you in June). Immediately Immediately Immediately Immediately Immediately Immediately Immediately Please refer to page 17, your course selection is not guaranteed until your tuition is paid in full June 1, 2015 June 1, 2015 June 1, 2015 Bring on Registration Day Bring on Registration Day Complete by Registration Day Bring on Registration Day Forms may be submitted separately. When sending forms or payment, please use one of these methods: By Email By Mail JSA Summer School 1411 K St. NW, Suite 200 Washington, DC 20005 United States Date Due By Fax (please bring originals on Opening Day) (please bring originals on Opening Day) [email protected] 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE (202) 296-‐7839 15 Par ental Per mission For m Student Information Stanford UVA Student Name Home Address City State Zip code Phone Gender: Male High School I will be attending the 2015 JSA Summer School at: Georgetown I Georgetown II Princeton Female Age Social Security Number -‐ -‐ (Necessary for access to government buildings) Birth Date / / (mm/dd/yyyy) High School Graduation year: City and State (or country) of Birth (Necessary for access to government buildings) Parent Statement I have read the JSA Summer School Orientation Guide, and I agree to allow my son/daughter to attend the 2015 JSA Summer School, subject to all rules governing conduct both on and off campus. I understand that my son/daughter may be sent home during the session for any serious conduct violations or for health reasons. I understand that if my child withdraws early from the program, or if he/she is sent home for health reasons or for violations of the rules and regulations of the JSA Summer School, the university, or any public law, that no refund will be given and no academic credit will be received. This is to authorize JSA Staff to authorize medical personnel to provide necessary medical care to my child. I give permission for the JSA staff to dispense the limited over-‐the-‐counter medicines outlined in the medical form and understand my child will be responsible for taking their own prescription medications. I give permission for the nearest or most appropriate medical facility to provide routine health care for my child; to order x-‐rays, tests or treatment; and to release any records necessary for insurance purposes. In the event I cannot be reached during an emergency, I give permission for the physician selected by the JSA staff to secure and administer treatment, including surgery or hospitalization, for the student named above. I give permission for JSA to contact my child’s medical provider for the purpose of confirming medical conditions/ treatments or obtaining additional information in order to provide appropriate care. The authorization shall be in effect while my child is a stu-‐ dent of the JSA Summer School. I understand I am fully responsible for my child’s medical costs. I understand and agree that additional costs to house, feed and transport my child home after the last day of their program is my financial re-‐ sponsibility. If my child is delayed for any reason on the last day of their program, I agree to pay $50 per night past that date. Also, I understand this option is to be used only in emergencies and is not available as an optional extension. I understand and agree that photographs taken of my son/daughter while at JSA Summer School may be used by the Junior Statesmen Founda-‐ tion for future promotional purposes. I understand and agree that quotations written by my son/daughter while at JSA Summer School may be used by the Junior Statesmen Founda-‐ tion for future promotional purposes. Date Parent Signature STUDENT STATEMENT -‐ I have read the JSA Summer School Orientation Packet and I agree to abide by all the Summer School rules. I under-‐ stand that in the event of a serious violation of the rules, my parents will be notified and I may be sent home at my own expense, with no refund or academic credit awarded. Date Student Signature The U.S. Department of Education requires that we collect and report race and ethnicity data on our students. The parent or legal guardian of the student is required to answer the following questions. *(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Span-‐ (1) Is this student Hispanic/Latino*? (choose only one) Yes No ish culture or origin, regardless of race) (2) What is the student’s race? (choose only one) American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, who maintains a tribal affiliation or community attachment.) Asian (A person having origins in any of the peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.) Black or African American (A person having origins in any of the Black racial groups of Africa.) Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.) Does this student participate in the federal free/reduced lunch program at his/her school: (3) 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE Yes No 16 Payment Infor mation The Summer School tuition ($4950 for Georgetown/Princeton/Stanford; $5250 for University of Virginia) covers housing and on-‐ campus meals, faculty, guidance and supervision, as well as textbooks and other academic expenses. Students must pay for their own meals during off-‐campus trips. Option 1: Tuition in full is due within 10 business days after receipt of acceptance letter and Orientation Guide. Option 2: If paying tuition in full poses a hardship, then students must take the following steps within 10 days after receipt of acceptance letter and Orientation Guide to avoid being Wait Listed. 1. 2. 3. 4. JSA Members: Email [email protected] -‐ Payment plan agreement will be emailed to you. Non-‐JSA Members: Contact Mr. Slade Jones at 202-‐486-‐0651 or [email protected] -‐ Payment plan agreement will be emailed to you. Visit www.summer.jsa.org/fundraising to learn about and sign up for a JSA Fundraising Academy Webinar offered each week on Tuesday and Wednesday evenings. Start an online fundraising webpage at www.jsa.org/summerfundraising Accepted students will be Wait listed if no payment plan is set up within 10 days after receipt of acceptance letter and Orientation Guide. When a program’s seating capacity is reached, Wait Listed students are notified and may be un-‐enrolled from the program if they do not adhere to the agreed upon payment plan. * Due to limited space in each program, your seat is only guaranteed when tuition is paid in full. PAYMENT OPTIONS For any payment, always include the NAME of the student and the PROGRAM the student is attending (i.e. John Doe, Stanford) • • • • BY CREDIT CARD We accept Visa, MasterCard, American Express and Discover. Pay by completing the Tuition Payment Form or by phone at (800) 317-‐9338 BY CREDIT CARD -‐ ONLINE Please send an email to [email protected] and request an online payment link to your invoice or make payment online through MyJSA account. BY CHECK OR MONEY ORDER Please make checks payable to the Junior Statesmen Foundation. Include the name of the student and the program they are attending on the check (i.e. John Doe, Stanford). Send all check/money orders to: JSA Summer School 1411 K St. NW | Suite 200 Washington, DC 20005 DOMESTIC OR INTERNATIONAL CABLE Please call (800) 334-‐5353 or (650) 347-‐1600 for routing number and instructions. Partial scholarships are available from the Junior Statesmen Foundation. Students may submit a scholarship application at any time before May 1, 2015. The JSA Scholarship Application is available at www.summer.jsa.org/support/scholarships/ REFUNDS Tuition payments (minus a $75 administrative fee) made by the immediate family (parents, grandparents, brothers and sisters) are fully refundable as long as the Junior Statesmen Foundation receives notice in writing at least 15 business days before the start of your program. After this date, all tuition fees paid become non-‐refundable, but will remain on the student’s account to be used for any future JSA Summer Programs or events. • Junior Statesmen Foundation scholarship funds are not refundable at any time. • All refunds must be requested in writing at least 15 business days before the start of your program. • There will be no refund of tuition for any students who withdraw for any reason before the end of the session or who are dismissed for disciplinary or other reasons. 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE 17 Tuition Payment For m Student Name Home Address City State Zip PAYMENT INFORMATION Enclosed is $4950, my full tuition payment (Georgetown/Stanford/Princeton) Enclosed is $5250, my full tuition payment (University of Virginia) Other amount $___________ (Payment Plan option only) We are p aying by: Check (made payable to the Junior Statesmen Foundation) Card Number Visa MasterCard American Express _________________________________________Exp. Date Discover CID # _____VISA, MC, DISC: 3-‐digit code on the back AMEX: 4-‐digit code on the front Card Holder’s Name Card Holder’s Signature Billing Zip Code Amount to Charge $ By Email By Mail JSA Summer School 1411 K St. NW, Suite 200 Washington, DC 20005 United States By Fax (please bring originals on Opening Day) (please bring originals on Opening Day) [email protected] 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE (202) 296-‐7839 18 Medical Infor mation For m, par t 1 This form should be filled out by the parent/guardian and returned to JSA immediately. Student Information Student Name Campus Address City, State, Zip Father/Guardian Mother/Guardian Daytime Phone Daytime Phone Evening Phone Evening Phone Cell Phone Cell Phone Email Email First Emergency Contact (other than guardian) Second Emergency Contact (other than guardian) Relationship to Student Relationship to Student Daytime Phone Daytime Phone Evening Phone Evening Phone Cell Phone Cell Phone Medical Insurance All students must bring to campus a photocopy of both sides of your insurance and pharmacy cards (front and back) Medical Insurance Provider Policy/Group No. Address of Insurance Company Name of Policy Holder Date of Birth of Policy Holder Employer of Policy Holder Prescription Card No. Medications You Will Have On Campus (Please note that the Junior Statesmen Staff will only administer Advil or Tylenol and no other medications. If your child is prone to stomach aches, colds and cough-‐ ing, it is your responsibility to pack whatever over-‐the-‐counter medications they might require. Also, the Junior Statesmen Foundation staff will not be responsible for administering necessary prescription medications to your child.) My child does NOT take regular prescription medication at this time. My child DOES take regular prescription medication at this time. Medication Name Medication Name Medication Name Return this form WITH the next page to: By Email By Mail JSA Summer School 1411 K St. NW, Suite 200 Washington, DC 20005 United States Medication Name By Fax (please bring originals on Opening Day) (please bring originals on Opening Day) [email protected] 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE (202) 296-‐7839 19 Medical Infor mation For m, par t 2 This form should be filled out by the parent/guardian and returned to JSA by June 1, 2015. Allergies Do not give my child the following medications under any circumstances: My child is allergic to the following medications, food, insect bites, etc. Does your child carry an EpiPen for allergies? Yes No Medical History My son/daughter has the following health problems/special needs of which you should be aware: Does your child have a history of operation or serious illness? Is your child under the care of a psychologist, psychiatrist or counselor? If so, please provide relevant details. Include additional documents if necessary. Is there anything else that we should know about your child’s physical or mental state? I signify this medical information is true to the best of my knowledge Date Return this form WITH the previous page to: By Email By Mail JSA Summer School 1411 K St. NW, Suite 200 Washington, DC 20005 United States Parent/Guardian Signature By Fax (please bring originals on Opening Day) (please bring originals on Opening Day) [email protected] 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE (202) 296-‐7839 20 Physician’s Signatur e For m This form should be returned to JSA by June 1, 2015. To be Completed by Parent/Guardian Campus Student Name Medical History Date of Physical Exam (must be within the last 2 years) Should JSA be aware of any disabilities, dietary restrictions, or Mental or physical health issues that the student may have? Yes Describe No Are there any physical activities from which the student should be restricted from participating? Yes No Describe Is the student taking any medications? Describe Immunizations: Please attach a separate sheet with all immunizations or provide dates for the shots listed below. DPT MMR 1st 1st 2nd 2nd 3rd 4th Polio 1st 2nd 3rd 4th Date of last tetanus booster Meningococcal (not required) Hepatitis B (not required) Haemophilus Influenza Type B (not required) Tuberculosis skin test (required for students traveling from outside the U.S.) If positive, can this person participate in the program and not be a danger to himself or others? Yes No Varicella (chicken pox) (not required) PHYSICIAN’S STATEMENT To the best of my knowledge, the student is in good mental and physical health, is up to date with required immunizations and should be able to complete and participate in casual recreation-‐ al activities in a Junior Statesmen program, unless otherwise noted on this form. Date Physician’s Signature/Stamp Return this form to: By Email By Mail JSA Summer School 1411 K St. NW, Suite 200 Washington, DC 20005 United States Physician’s Name, Address and Phone Number By Fax (please bring originals on Opening Day) (please bring originals on Opening Day) [email protected] 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE (202) 296-‐7839 21 Roommate Request For m (optional) The housing lists for JSA Summer Schools will be submitted to the university by early June. If you have a pref-‐ erence for your roommate, please complete this form and return it to us by May 27, 2015. The tuition of both students must be fully paid by the deadline if the roommate request is to be honored. Also, both students must submit a request form asking to be roomed with each other. All requests must be in writing. Please complete the following information Your Name Your Address Your Phone Number Your High School High School Graduation Year Name of the person with whom you wish to room Requested Roommate’s Phone Number Return this optional form to: JSA Summer School 1411 K St. NW, Suite 200 Washington, DC 20005 United States By Email By Mail By Fax (please bring originals on Opening Day) (please bring originals on Opening Day) [email protected] 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE (202) 296-‐7839 22 Summer Tr anspor tation For m Very important: All students are required to fill out this questionnaire regardless of how you are arriving on campus. Please include a copy of your airline itinerary when you return this form (if applicable). Please refer to the “Campus-‐Specific Information” section of this guide (page 25) if you have questions. The form is due June 1, 2015. Student Name Student Cell Phone Number (on day of travel) Campus Parent Cell Phone Number (on day of travel) I will be arriving by Adult-‐Driven Automobile Plane Bus Train I will be departing by Adult-‐Driven Automobile Plane Bus Train I will need a shuttle on Opening Day Yes No I will need a shuttle on Departure Day Arrival Information Departure Information Originating Airport Flight/Train/Bus Number Flight/Train/Bus Number Airline Airline Arrival Time (PST for Stanford, EST for Princeton/Georgetown/UVA) Departure Time (PST for Stanford, EST for Princeton/Georgetown/UVA) p.m. Date a.m. Connecting Flight (if applicable) Yes No p.m. Date Connecting Flight (if applicable) Yes No Connecting through city Connecting through city Flight/Train Number Flight/Train Number Airline Airline Destination Airport (i.e. Dulles, Reagan, SFO, Newark) Destination Airport Return this form to: By Email By Mail JSA Summer School 1411 K St. NW, Suite 200 Washington, DC 20005 United States (not required if “Adult-‐Driven Automobile” was checked) Originating Airport a.m. No Travel Itinerary (not required if “Adult-‐Driven Automobile” was checked) Yes By Fax (please bring originals on Opening Day) (please bring originals on Opening Day) [email protected] 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE (202) 296-‐7839 23 Cour se Change Request For m For students who have already taken an American Government, AP U.S. History and/or Speech Communication course, we recommend choosing one of the other classes listed below. Freshman Scholars are not eligible for these courses. Return this form by June 1, 2015. Student Name Age High School High School Graduation Year I would like to take the following course Honors Constitutional Law Speech & Political Communication Honors Media & Politics Advanced Placement U.S. Government Honors International Relations Advanced Placement Macroeconomics What grade were in when you took U.S. History? Level of your U.S. History Course Honors Advanced Placement Other (please specify) What was your final grade in U.S. History? A B Other (please specify) Have you taken A.P. American Government at a JSA Summer School? Yes No If Yes, in what year and at what campus? Have you taken A.P. American Government at your High School? Yes No What was your final grade in American Government? A B Other (please specify) Please write a brief paragraph on why you would like to take the course you’ve selected. Return this optional form to: JSA Summer School 1411 K St. NW, Suite 200 Washington, DC 20005 United States By Email By Mail By Fax (please bring originals on Opening Day) (please bring originals on Opening Day) [email protected] 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE (202) 296-‐7839 24 20 15 J SA SUM M ER SC HO OL O R IE NTAT ION GUIDE 25
© Copyright 2024