APHIS Form 119 Ag-Discovery Application

APPLICATION

Student’s Full Name:
Address:	Street
	City		State			ZIP code
Telephone Number:
Email Address:
Date of Birth:			Age
Gender:	Male			Female
T-Shirt Size	S M L XL XXL
School Name			Grade in the fall of 2010
School Address	Street
	City		State			ZIP code
	Please include Proof of School Enrollment (Last Report Card, Transcript, or Letter from the School)

Special Food/Dietary Restrictions: ___________________________________________________________________

Do you have any health problems or disabilities that require special attention? If yes, please describe:

_______________________________________________________________________________________________

If you are selected to participate in the Ag-Discovery Program you will be required to provide the following. (Please do not send these documents with your application).

1. A copy of your IMMUNIZATION FORM from your physician or local health department

2. Proof of health coverage

Name and Phone Number of Parent or Guardian: _______________________________________________________

Name and Phone Number of Emergency Contact, if different from above: ___________________________________

PARTICIPATING UNIVERSITIES: (Select the Ag-Discovery Program you are applying for.

(Please submit a separate complete application package for each selection).

√	University	Program Date
( )	South Carolina State University (SCSU)	June 6 – 19
( )	Florida A & M University (FAMU)	June 6 – 18
( )	University of Arkansas at Pine Bluff (UAPB)	June 12 – 25
( )	Kentucky State University (KSU)	June 13 – 26
( )	Alcorn State University (ASU)	June 13 – 25
( )	University of Arizona (UOA)	June 21 – July 2
( )	Delaware State University (DSU)	July 5 – 19
( )	Iowa State University (ISU)	July 11 – 24
( )	University of Maryland at College Park (UM)	July 11 – 31
( )	North Carolina State University (NCSU)	July 12 – 23

Have you participated in a previous Ag-Discovery Program? Yes ___ No ___ If yes, which year and location?

_______________________________________________________________________________________________

If selected to participate in the Ag-Discovery program, I promise to abide by the rules and regulations that govern the program and to make proper use of the educational advantages offered. If for any reason I violate any part of the Student contract, I acknowledge that I can be dismissed from the Ag-Discovery program and sent home immediately.

I affirm that the information given above is true to the best of my knowledge.

Student’s Signature: _____________________________________________ Date: ____________________________

Student’s Full Name: ______________________________________________________________________________

Parent/Legal Guardian’s Signature: _________________________________ Date: ____________________________

ESSAY

ON A SEPARATE SHEET OF PAPER, PLEASE PREPARE A 2-PAGE ESSAY WHICH ADDRESSES THE FOLLOWING QUESTIONS:

• Why I Want to Attend the AG-Discovery Program at _________________________________________

(Insert the name of the participating university you would like to attend)

• What I Want to Learn

• What I Want to do When I Grow Up

• What are Some of my Hobbies and Interests

APPLICATION MUST BE POSTMARKED BY APRIL 10, 2010

PARENTAL RELEASE FORM

I certify that my child, ________________________________, who is enrolled with this agreement, is in excellent health and may participate in strenuous physical activities associated with the Ag-Discovery Summer Enrichment Program. I agree to defend, indemnify, and hold harmless USDA-APHIS and the selected university, its officers, servants, agents and/or employees, contractors, and insurers from any and all claims for injuries sustained by my child during his/her participation in this program.

Permission is hereby granted to the U.S. Department of Agriculture and _______________________________ (Name of University) to use pictures of my child in any promotional materials as well as to travel on field trips both in and out of State. Permission is granted in the agreement for my child to receive emergency medical treatment, if needed, and I certify there are no limits to my child’s participation in the Ag-Discovery activities except as stated in writing and included with the medical history.

I understand and acknowledge that Ag-Discovery does not offer any medical insurance to protect against injuries, makes no claims to do so, and has no responsibility for any medical expenses incurred. I understand that each participant must assume the risk and any related financial responsibility that could result from participation in any of these activities. I agree to assume any risk and financial responsibility.

I have received a copy of the Student Contract, and I have reviewed it with my child.

Parent/Legal Guardian’s Signature: ______________________________ Date: ______________________

APPLICATION MUST BE POSTMARKED BY APRIL 10, 2010

Student Contract

Acceptance into the Ag-Discovery program is a privilege, but it also requires students and parents to assume certain responsibilities.

Student: I, ___________________________________, as a participant in the Ag-Discovery summer youth enrichment program sponsored by USDA-APHIS and ___________________________________ (Name of University) do hereby accept the conditions stipulated below:

1. I will participate in and be on time to all sessions and activities, unless excused by a staff member.

2. I will conduct myself in a respectful and courteous manner at all times.

3. I will sleep where assigned and realize that I will be in constant contact with people from varying cultures and ethnic affiliations.

4. I understand that there are guidelines regarding lights-out and bedtime and that there will be a bed check every night by a chaperone.

5. I will not smoke or use drugs or alcohol during Ag-Discovery and I understand that by doing this, I will be sent home immediately AT MY PARENTS’ EXPENSE.

6. I understand that I may be held responsible for any damage to equipment or facilities.

7. I understand that all profanity, horseplay, fighting, or inappropriate acts is prohibited.

8. I understand no electronic equipment including TVs, portable radio/CD players, or computer games will be allowed. The only exception is a clock/radio.

9. I understand that I am not allowed to have a personal vehicle on campus as an Ag-Discovery participant.

10. I will wear appropriate attire at all times during the Ag-Discovery program. Appropriate clothing includes khaki shorts, denim shorts, t-shirts, one-piece swimsuit, tennis shoes, and/or sandals. I am NOT allowed to wear overly provocative or offensive clothing.

11. I will adhere to these and all other rules of the Ag-Discovery staff.

Student’s Signature: __________________________________________ Date: ______________________

Picture Release Statement

As parent(s) of ________________________________ I/we fully understand the conditions stipulated above and hereby give full consent to USDA-APHIS and the selected university to reproduce my child’s picture in future promotional material.

Parent/Legal Guardian’s Signature: ______________________________ Date: ______________________

APPLICATION MUST BE POSTMARKED BY APRIL 10, 2010

Summer Enrichment Program

Letter of Recommendation For:

___________________________________________

(Student’s Name)

Student: Please give this to three adults (one must be a teacher or counselor) who know you and are familiar with your schoolwork, interest in agriculture, and work qualities. (FOR EXAMPLE: a job supervisor, teacher, counselor, elder, minister, NOT A RELATIVE).

Respondent: The student named on this form is being considered for participation in the Ag-Discovery Program, a summer enrichment program at _____________________________________ (Name of University) sponsored by the United States Department of Agriculture, Animal and Plant Health Inspection Service. Please complete this form (you may use a separate sheet of paper if needed).

Your Name:			Title
Address:	Street
	City		State		ZIP code
Telephone Number:

PLEASE ADDRESS THE QUESTIONS LISTED BELOW:

• How do you know the student?

• How long have you known the student?

• What do you know about the student’s character, aptitude for learning, and interest in agriculture, if known?

Signature of Respondent: ___________________________________________________ Date: ______________________

Your letter is confidential: Please note the deadline for receiving the application and related materials is April 10, 2010.

Send this form along with any additional pages to complete the Letter of Recommendation in a sealed envelope to:

USDA-APHIS-CREC

Attn: Beatrice Jacobs

4700 River Road, Unit 92

Riverdale, MD 20737

If you have any questions, please contact Ms. Beatrice Jacobs ([email protected]) or

Ms. Terry Henson ([email protected]) at (301) 734-6312.

APPLICATION MUST BE POSTMARKED BY APRIL 10, 2010

Checklist

A complete application package should include the following materials:

• Completed Signed Application

• 2-page Essay

• Parental Release Form

• Three Letters of Recommendation - one recommendation must be from a certified teacher or counselor

The letters must be mailed separately by respondents

• Proof of Age (copy of birth certificate, driver’s license, etc.)

• Proof of School Enrollment

• Signed Student/Parent Contract and Signed Picture Release Statement

PLEASE MAIL YOUR COMPLETE APPLICATION PACKAGE TO:

Ms. Beatrice Jacobs

USDA, APHIS, Office of the Administrator

Civil Rights Enforcement and Compliance

4700 River Road, Unit 92

Riverdale, MD 20737–1234

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-XXXX. The time required to complete this information collection is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB Approved 0579-XXXX EXP. XX/XXXX

APPLICATION MUST BE POSTMARKED BY APRIL 10, 2010

APHIS FORM 119 PAGE 8 of 8 JAN 2010