2016 Program Application

Transcription

1 George Biddle Kelley Education Foundation, Inc. Alpha Esquires 2016 Program Application

2 Alpha Esquire (ESQ) Mentorship Program Description & Overview: The Alpha ESQ mentorship program is designed to provide education, motivation and skill-building in the areas of personal responsibility, relationships, entrepreneurship and financial literacy for young males ages years. The goals of our interactive mentorship program are to share knowledge by combating ignorance and fear with factual information, debunking myths by taking a critical look into popular culture; and increasing skills by creating a sense of empowerment and self-esteem. Criteria: Any college bound, motivated, or at-risk male living and attending school in the Capital Region who is willing to participate. All prospective participants must complete the attached application and consent forms. Key Dates: The Alpha ESQ program runs during the second semester of the academic year from January June with sessions generally occurring twice monthly on Sunday afternoons. Regular sessions will occur on Sundays beginning on February 13, 2016 and will run through July 9, 2016 (dates are subject to change). There are additional key dates, enrichment and team building activities included in the program include: Saturday, January 23, 2016: Application Deadline Sunday, February 6, 2016: Parent Orientation Saturday, February 13, 2016: Black Family Technology Awareness Day Sunday, February 28, 2015: First Session Sunday, April 24, 2016: Bus Trip to New York National College Fair Saturday, July 9, 2016: Fraternity BBQ & End of Year Awards Event Please fill out the attached application and parent permission form and mail or all documents to: George Biddle Kelley Education Foundation, P.O. Box 14692, Albany, NY or gbkfoundation@gmail.com The George Biddle Kelley Education Foundation, Inc. (GBK) was formed with a mission to engage in activities that provide information, resources, advocacy, programs and services to assist in the development of strong families in at-risk communities. The GBK Education Foundation works in conjunction with other national and local organizations to promote events and programs that benefit these communities by providing scholarships, conducting college bus tours, and hosting workshops to increase our youth s awareness about responsibility, leadership, and entrepreneurship. The GBK Education Foundation is named in honor of Troy, New York native and resident George Biddle Kelley ( ). Born to a former fugitive slave from Virginia, Kelley would excel in studies in his youth as a student at Rensselaer Polytechnic Institute before he matriculated to Cornell University to study civil engineering. There he would become one of the seven founding members of Alpha Phi Alpha, the oldest Greek letter fraternity organized originally for Black men. Alpha Esquires 2016 Program Application Kelley would return to Troy after college to become the first African-American engineer registered in New York State. He was also one of Troy s leading civic and social leaders in the 1940 s and one of the major proponents of improved race relations. The aims of the Alpha Phi Alpha, Manly Deeds, Scholarship, and Love for All Mankind, along with Kelley s intense community involvement, are emulated by the membership of the foundation.

3 Alpha Phi Alpha Fraternity, Inc. & George Biddle Kelley Foundation, Inc. P.O Albany, NY (518) Please print all responses: Participant Application Form Name: D.O.B. Age: Grade: School: GPA: Home Address: City State Zip Phone Number: Facebook Screen Name: Twitter Account Name: Parent/Guardian Contact Information Name: Relationship: Home Address: City State Zip Home Telephone #: Work Phone #: Cell Phone #: Facebook Screen Name: Twitter Account Name: This application must be accompanied by a letter of recommendation from a Teacher, School Administrator, Guidance Counselor, Community Leader, Pastor, or Employer on related letterhead. Please attach. By choosing to participate in the Alpha Esquire program, I agree to: Follow all rules and guidelines as outlined by the Program Director during the orientation session; Have a positive attitude and be respectful of the program; Be on time for scheduled sessions or call the Program Director at least 24 hours beforehand if I am unable to make a session; Inform the Program Director of any difficulties or areas of concern that may arise; and Immediately notify the Program Director if I have any changes in address or phone number. I agree to follow all the above stipulations of this program as well as any other conditions as instructed by the Program Director at this time or in the future. PARTICIPANT SIGNATURE & DATE In lieu of signature check this box if submitting electronically. PARENT/GUARDIAN SIGNATURE & DATE In lieu of Signature Check this box if submitting electronically.

4 Alpha Phi Alpha Fraternity, Inc. & George Biddle Kelley Foundation, Inc. P.O Albany, NY (518) Authorized Pick-up Information CHILD S NAME: Please select acceptable form of transportation: Parent/Guardian Public Transportation/Bus Relative Taxi Walk Other Please list below any people you authorize to pick up your child. NAME: RELATIONSHIP: PHONE #: NAME: RELATIONSHIP: PHONE #: If there are additional people you authorize to pick up your child, please list them below. DISCLAIMER: Minor children will not be released to other minors, nor will they be released to unknown persons lacking proper identification; Minor children will not be released to those who appear to be under the influence of drugs, alcohol or illegal substances; A parent or guardian MUST attend the February 8, 2015 Alpha ESQ orientation session; If a parent or guardian does not attend the orientation, the applicant must have a notarized application form; I hereby authorize any of the people listed above to pick up my child if I am unable to do so myself. PRINT PARENT S/LEGAL GUARDIAN NAME CLEARLY PARENT S SIGNATURE & DATE In lieu of signature, check this box if submitting electronically.

5 Waiver of Liability and Hold Harmless Agreement The Foundation will be relying on adult volunteers to provide the mentoring, monitoring and other necessary supervision to assure the safe participation of the young people enrolled in this program. We need to provide the following assurance that the volunteers would be legally protected in the unlikely event an unfortunate circumstance arises when they are generously donating their time and attention to this beneficial program. I,, in consideration of my participation in the Alpha Esquire program hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the facilitators, their officers, servants, agents, or employees (hereinafter referred to as RELEASEES ) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES or otherwise, while traveling to/from GBK s Alpha ESQ program or their activities, while participating in such activity, or while in, on or upon the premises where the activity is being conducted. I am fully aware of the risks and hazards connected with participating in such activity, including the risk of injuries which can cause death, and hereby elect to voluntarily participate in said activity, and to enter the above-named premises and engage in such activity, knowing that the activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or costs, including court costs and attorney s fees, that may incur due to my participation in said activity WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASEE, WAIVER, DISCHARGE and COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of New York. I sign this agreement voluntarily as my own free act and deed; no oral representations, statements, or inducement, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same. IN WITNESS WHEREOF, I have hereunto set my signature on (month) (day), (Year). PARENT S SIGNATURE & DATE In lieu of Signature Check this box if submitting electronically.

6 CODE OF PARTICIPANT CONDUCT The Code of Participant Conduct is the Foundation s policy that creates a safe learning environment to ensure program success. If this objective is to be accomplished, it is necessary that the program environment be a safe and supportive community. A positive program climate not only supports achievement but promotes fairness, civility, acceptance of diversity, and mutual respect. Behavior and Language. Below is a list of items that student must adhere to during the program. Disorderly Conduct: Insubordinate Conduct: Violent Conduct: Conduct that Endangers the Safety, Morals, Health, or Welfare of Others: Using profane language. Running in hallways/buildings. Making unreasonable noise. Dangerous horseplay. Failing to comply with reasonable directions of program staff. Leaving the program without program staff knowledge. Lying to program personnel. Assault on others / fighting. Possessing a weapon. Threatening to use a weapon. Defamation. Intimidation or bullying. Illegal substances violations. Gambling. Indecent exposure. Consequences. The code of conduct must include a list of all possible consequences for violations of the rules. Examples, from least to most severe, include: Verbal warning Written warning Notification of parents / guardian / law enforcement if warranted Time out Cleaning up / Community Service / Physical Training Suspension from Alpha Esquire activities Expulsion from Alpha Esquire activities PARTICIPANT SIGNATURE & DATE In lieu of signature, check this box if submitting electronically. PARENT/GUARDIAN SIGNATURE & DATE In lieu of signature, check this box if submitting electronically.