Form APHIS FORM 119 APHIS FORM 119 AgDiscovery Application

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 number for this information collection is
0579-0326. The time required to complete this information collection is estimated to average 2.00 hours per response, including the
time to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing
the collection of information.

AgDiscovery 20XX

United States Department of Agriculture
Animal and Plant Health Inspection Service
Office of Civil Rights, Diversity, and Inclusion

Student’s Name

APPLICATION

First:

Middle Initial:

Home Address Street
City
Telephone Home (

OMB Approved
0579-0362
EXP XX/XXXX

Last:

State
)

Zip Code

Mobile/Cell (

)

E-mail Address
Date of Birth

/

Current Age:

/

Gender:

School Name

Male____

Female____

Grade in the Fall 20XX:
High School Graduation Year:

School Street
Address
City

State

Zip Code

Parent/Guardian’s
Name
Telephone Number Home (

)

Mobile/Cell (

)

Parent/Guardian’s
E-mail Address
Emergency Contact
Name

Telephone Number
Home: (
)
Mobile/Cell: (
)

Select the AgDiscovery Program you wish to apply for below. PLEASE ONLY SELECT ONE.


University
Alcorn State University
California State University, Fresno
Coppin State University
Delaware State University
Florida A&M University
Fort Valley State University
Iowa State University
Kentucky State University
Lincoln University – Missouri
North Carolina State University
Prairie View A&M University
Purdue University
South Carolina State University
Tuskegee University
University of Arizona
University of Arkansas at Pine Bluff
University of Hawaii at Mānoa
University of Illinois at Urbana-Champaign
University of Maryland College Park
University of Maryland Eastern Shore
University of the Virgin Islands
Virginia State University

APHIS FORM 119

20XX Program Dates

Age Requirements
12-16 years old
15-17 years old
15-17 years old
14-17 years old
14-17 years old
14-17 years old
15-17 years old
14-17 years old
14-17 years old
15-17 years old
15-17 years old
15-17 years old
14-17 years old
15-17 years old
15-17 years old
14-17 years old
14-17 years old
15-17 years old
15-17 years old
14-17 years old
14-17 years old
15-17 years old

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 XX/XXX
AgDiscovery Program Application
Page 2

How did you find out about AgDiscovery?
AgDiscovery Website

Teacher

Facebook

Other Source:

Friend

Counselor

Have you participated in an AgDiscovery Program in the past?
If yes, please list the year

Yes______

YouTube Video

No______

Which location?

If you are selected to participate in the AgDiscovery Program, you will be required to provide the following
documentation:
• Proof of age
• Proof of school enrollment
• Current high school transcript (for University of Maryland College Park
applicants only)
Please DO NOT send those documents with your application.
IMPORTANT NOTE: Applicants selected to attend the AgDiscovery program are required to attend the program
in its entirety. Please do not apply if you have any obligations (i.e., vacation plans, summer camps, etc.) that
will prevent you from attending the entire AgDiscovery program, which includes weekends, and opening and
closing day activities.

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 XX/XXX
AgDiscovery Program Application
Page 3

AgDiscovery 20XX
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
AgDiscovery Summer 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 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 AgDiscovery activities,
except as stated in writing, and included with the medical history.
I understand and acknowledge that AgDiscovery 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:

____

PICTURE AND VIDEO RELEASE STATEMENT
As parent/guardian of
,
I fully understand the conditions stipulated above, and hereby give full consent to USDA-APHIS and the
selected university to reproduce my child’s picture and/or video in future promotional material. 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.

Parent/Legal Guardian’s Signature:

________Date:

APPLICATION MUST BE RECEIVED/POSTMARKED BY XXXX, 20XX

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.

AgDiscovery 20XX

OMB Approved
0579-0362
EXP XX/XXX
AgDiscovery Program Application
Page 4

STUDENT CONTRACT
Acceptance into the AgDiscovery Program is a privilege, but it also requires students and parents to
assume certain responsibilities.
Student: I,
_______________________as a participant in AgDiscovery, a
summer youth enrichment program sponsored by USDA-APHIS and
(insert 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 AgDiscovery, and I understand that
by doing this, I will be sent home immediately AT MY PARENT’S EXPENSE.
6. I will not engage in fraternization, cohabitation or co-mingling of any kind during the
program. Friendships are encouraged from a platonic standpoint only. Any disregard
in this matter, or any other infractions may be cause for dismissal from the program,
and my parents will be alerted of the misconduct.
7. I understand that I may be held responsible for any damage to equipment or facilities.
8. I understand that all profanity, horseplay, fighting, or inappropriate acts is prohibited.
9. I understand that other than a clock/radio, no electronic equipment (including TVs, portable
radios/CD players, or computer games) will be allowed.
10. There will be no aggressive behavior tolerated at any time. This includes fighting, bullying,
cyber-bullying, undue persuasion, assault, cursing, and general disregard for myself, and the
people around me.
11. Student will respect the dormitories and other facilities on and off campus, at all times.
12. The use of cell phones and other handheld devices is strictly prohibited during the
presentations. For any such misuse, the instrument will be confiscated until the end of
the program.
13. AgDiscovery participants are not allowed to have personal vehicles on campus.
14. 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.
15. 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.
16. I will adhere to these and all other rules of the AgDiscovery program.
If selected to participate in the AgDiscovery 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
AgDiscovery Program, and sent home immediately.
I affirm that the information submitted in my application package is true to the best of my knowledge.
Student’s Signature:
Student’s Full Name:

Date:

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 XX/XXX
AgDiscovery Program Application
Page 5

AgDiscovery 20XX
ESSAY
The essay must:
•

Be typed or legibly handwritten

•

Be prepared in blue or black ink (no pencil or colored ink)

•

Include your name, address, age, telephone number, and email address on the first page

•

Be two (2) pages in length
•

•

Be a minimum of 500 words, and a maximum of 1,000 words

Address the topics below:
▪

Why I Want to Attend the AgDiscovery Program

▪

What I Want to Learn

▪

My Future Career Goals and How I Plan to Achieve My Goals

▪

My Hobbies and Interests

▪

Describe your interest in agricultural sciences, any agricultural science-related
courses you have taken, as well as any extracurricular or volunteer activities you
have participated in related to agricultural, plant, animal, or biological science.

APPLICATION MUST BE RECEIVED/POSTMARKED BY XXXX, 20XX

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 XX/XXX
AgDiscovery Program Application
Page 6

AgDiscovery 20XX
CHECKLIST
A complete application package must include the following materials:
•

Completed and signed application form

•

Signed Parental Release form

•

Completed and signed Student Contract and Picture and Video Release Statement

•

Two-page essay – 500 word minimum and 1,000 word maximum

•

Three (3) letters of recommendation (one from a teacher, school counselor, or school administrator)
You may complete your application online at www.aphis.usda/agdiscovery.
You also have the option to mail your application package to APHIS.
MAILED APPLICATION PACKAGES AND SEALED LETTERS OF RECOMMENDATION
SHOULD BE SENT IN ONE LARGE ENVELOPE TO:
USDA-APHIS AgDiscovery Program
ATTN: MS. TAMMY LOWRY
Office of Civil Rights, Diversity, and Inclusion
4700 River Road, Unit 92, Suite 6C-04.13
Riverdale, MD 20737-1234

You may complete the fillable PDF application online, at: www.aphis.usda.gov/agdiscovery, print it, and mail to
the address indicated above. Please remember to attach your essay.
Three reference letters must be included with your application package in sealed envelopes.
PLEASE NOTE: ONLY COMPLETE APPLICATION PACKAGES, CONTAINING THE LIST OF ITEMS
INDICATED ABOVE, WILL BE ELIGIBLE FOR CONSIDERATION. INCOMPLETE APPLICATION
PACKAGES AND SEPARATELY MAILED ENVELOPES WILL NOT BE CONSIDERED.
NO FAXED, E-MAILED, OR HAND-DELIVERED APPLICATIONS WILL BE ACCEPTED.

PLEASE APPLY EARLY!
DO NOT WAIT UNTIL THE LAST MINUTE!
APPLICATIONS MUST BE RECEIVED/POSTMARKED BY XXXX, 20XX

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 XX/XXX

United States Department of Agriculture
Animal and Plant Health Inspection Service
Office of Civil Rights, Diversity, and Inclusion

AgDiscovery 20XX
LETTER OF RECOMMENDATION
STUDENT’S NAME
Student: Please give this Letter of Recommendation to three (3) adults (one must be a teacher or counselor),
who know you, and are familiar with your school work, interest in agriculture, and work qualities. For example,
a supervisor, teacher, school counselor, coach, or minister, who is NOT A RELATIVE of yours. Please fill in
your name on the top of the form, and the name of the university for which you are applying, below.
Respondent: The student named on this form is being considered for participation in the AgDiscovery
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 on his/her behalf, and return to the student before XXXX, 20XX. You may use a
separate sheet of paper, if needed.
Your Name

Title

Your Relationship to Applicant
Address Street
City
Telephone (

State

Zip Code

)

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, ambition, aptitude for learning, and interest
in agriculture?

Signature of Respondent:

Date:

The information you provide is confidential. Please place your letter of recommendation in a sealed envelope
and return to the student. Letters of recommendation must be postmarked or received at USDA
by XXXX, 20XX, in order for the student to receive full consideration.