Form APHIS Form 119 APHIS Form 119 Ag-Discovery Application

APPLICATION
Student’s Full Name:
Street
City

Address:

State

ZIP code

Telephone Number:
Email Address:

Age

Date of Birth:

Male

Gender:

S

T-Shirt Size

Female
M

L

XL

XXL

Grade in the fall of 2013

School Name
School Address

Street
City

State

ZIP code

Special Food/Dietary Restrictions: ______________________________________________________________________________
Do you have any health problems or disabilities that require special attention? No
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).
• Proof of Age
• Proof of school enrollment
Name and Phone Number of Parent or Guardian: __________________________________________________________________
Parent or Guardian email address:______________________________________________________________________________
Name and Phone Number of Emergency Contact, if different from above: _______________________________________________
Emergency Contact email address:______________________________________________________________________________
PARTICIPATING UNIVERSITIES: (Select the Ag-Discovery Program you are applying for)
(Please select only one 2013 Ag-Discovery Program)

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APHIS FORM 119

University

2013 Program Dates

June 23 – July 7
June 9 – 22
July 7 – 20
June 9 – 22
June 9 – 22
June 15 – 28
June 16 – 28
June 17 – 28
June 16 – 29
June 17 – 28
June 17 – 28
June 30 – July 27
July 7 – 20
July 7 – 20
July 7 – 26
July 14 – 27
July 14 – 27

South Carolina State University (SCSU)
Tuskegee University (TU)
University of Hawaii at Monoa (UH)
Kentucky State University (KSU)
Florida A & M University (FAMU)
University of Arkansas at Pine Bluff (UAPB)
Alcorn State University (ASU)
North Carolina State University (NCSU)
Virginia State University (VSU)
Fort Valley State University (FVSU)
University of Arizona (UOA)
University of Illinois at Urbana – Champaign (UI)
Iowa State University (ISU)
Delaware State University (DSU)
University of Maryland at College Park (UM)
University of Maryland – Eastern Shore (UMES)
Lincoln University (LU)
PAGE 1 of 7

JAN 2010

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: ____________________________
Parent/Legal Guardian’s Signature: ___________________________________________________________________

APPLICATION MUST BE RECEIVED BY MARCH 23, 2013
APHIS FORM 119

PAGE 2 of 7

JAN 2010

ESSAY

The Essay Must:
•
•
•
•

Be typed or legibly written
Prepared in blue or black ink
Be a minimum of 500 and maximum of 1000 words
Address the questions below
•
•
•
•

Why I Want to Attend the AG-Discovery Program at
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 RECEIVED BY MARCH 23, 2013
APHIS FORM 119

PAGE 3 of 7

JAN 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 and video (s) 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 RECEIVED BY MARCH 23, 2013

APHIS FORM 119

PAGE 4 of 7

JAN 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 AG- DISCOVERY, a summer youth enrichment program sponsored by
USDA-APHIS and (_________________________________________________________)
insert university name
do hereby accept the conditions stipulated below:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

I will participate in and be on time to all sessions and activities, unless excused by a staff member.
I will conduct myself in a respectful and courteous manner at all times.
I will sleep where assigned and realize that I will be in constant contact with people from varying cultures and ethnic affiliations.
I understand that there are guidelines regarding lights-out and bedtime and that there will be a bed check every night by a
chaperone.
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 PARENT’S EXPENSE.
I will not engage in fraternization, cohabitation or co-mingling of any kind during the program. Friendships are
encouraged from a plutonic standpoint only. Any disregard in this matter or any other infractions may be cause for
dismissal from the program and parents alerted of the misconduct.
I understand that I may be held responsible for any damage to equipment or facilities.
I understand that all profanity, horseplay, fighting, or inappropriate acts is prohibited.
I understand that other than a clock/radio, no electronic equipment (including TVs, portable radio/CD players, or computer
games) will be allowed.
There will be no aggressive behavior tolerated at any time. That includes fighting, bullying, cyber-bullying, undue persuasion,
assault, cursing and general disregard for yourself and the people around you.
Student will respect the dormitories and other facilities on and off campus at all times.
The use of cell phones and other handheld devices is strictly prohibited during the presentations, any such misuse; the
instrument will be confiscated until the end of the program.
Ag-DISCOVERY participants are not allowed to have personal vehicles on campus.
Appropriate attire will include khaki shorts, denim shorts, t-shirts, one-piece swimsuit, tennis shoes, and/or sandals. No
student will be allowed to wear overly provocative or offensive clothing.
If there are any discrepancies of any kind they should be brought to the attention of supervision and handled accordingly, no
infractions of any kind should be handled by the students.
I will adhere to these and all other rules of the Ag-DISCOVERY program.

Signature of Student: ______________________________________________

Date: _____________

PICTURE and video RELEASE STATEMENT
As parent of __________________________ I fully understand the conditions stipulated above and hereby give full consent to USDAAPHIS and the selected university to reproduce my child’s picture and video in future promotional material.
Parent or Legal Guardian Signature ____________________________________

Date______________

APPLICATION MUST BE RECEIVED BY MARCH 23, 2013

APHIS FORM 119

PAGE 5 of 7

JAN 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, 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).
Title

Your Name:
Street
City

Address:

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 MARCH 23, 2013

Recommendation letters must be submitted in sealed envelopes within the application package
If you have any questions, please contact Ms. Beatrice Jacobs ([email protected]) or
Ms. Terry Henson ([email protected]) at (301) 851-4200.

APPLICATION MUST BE RECEIVED BY MARCH 23, 2013

APHIS FORM 119

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JAN 2010

Checklist
A complete application package should include the following materials:


Signed Application



Essay – 500 Word Minimum and 1000 Word Maximum



Signed Parental Release Form



Signed Student/Parent Contract and Signed Picture Release Statement



Three Letters of Recommendation - one recommendation must be from a certified teacher or counselor
o recommendation letters must be submitted in sealed envelopes within the application

package



If applying via email, reference letters must be submitted in sealed envelopes and mailed in
one package to the address below.

PLEASE MAIL YOUR COMPLETE APPLICATION PACKAGE TO:
Ms. Beatrice Jacobs
USDA, APHIS, Office of the Administrator
Office of Civil Rights, Diversity, and Inclusion
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 0579-0362. 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
0579-0362
EXP. 03/2013

APPLICATION MUST BE RECEIVED BY MARCH 23, 2013
APHIS FORM 119

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JAN 2010