UCSD TRiO Outreach Programs
Summer 2015, Resident Assistant (RA) Application
Application due April 3rd at 4pm, along with resume and letter of recommendation
Personal Information:
Name:_______________________________________________________________________________________
Last Name
First Name
Middle Initial
Cell Phone: __________________________________ Home Phone: ________________________________
UCSD Email Address: _________________________ Additional Email Address:__________________________
Current Address:_____________________________________________________________________________
Street
City/State
Zip Code
Major(s) and/or Minor(s):___________________________________________________________________
Do you have any relatives employed by UCSD? (Circle one)
If Yes: Please provide the following information;
YES
NO
Name:_______________________________________________________________________________________
Last Name
First Name
Middle Initial
Relationship to you: _____________________________ UCSD Department they work in:____________________
Please provide the name and contact information for two (2) PROFESSIONAL REFERENCES (community
leaders, church leaders, etc); must be different from the person who will submit a recommendation form.
Name: _________________________________________________
Title: ____________________________
Email Address: ______________________________________
Phone Number: _________________________
Name: _________________________________________________
Title: ____________________________
Email Address: ______________________________________
Phone Number: _________________________
Please provide the name and contact information for two (2) PERSONAL REFERENCES (family or friends);
must be different from the person who will submit a recommendation form.
Name: _________________________________________________
Title: ____________________________
Email Address: ______________________________________
Phone Number: _________________________
Name: _________________________________________________
Title: ____________________________
Email Address: ______________________________________
Phone Number: _________________________
Please rank which Academic Subject(s) that you can provide academic support for high school students?
____English ____Math (Algebra – Calculus) ____Science
____Language: _________________________
(French, Spanish, Arabic)
Disclosure of Misconduct
If any of the following answers are yes, please use a separate paper to describe the circumstances resulting in the
conviction, including disposition and dates. You may omit offenses settle in juvenile court or under a welfare
youth offender law, any incident sealed under “W&I Code Section 781 or Penal Code Section 1203.45 and any
conviction specified in Health and Safety Code 11361.5 pertaining to marijuana offenses.”
1. Have you ever been convicted of an offense by any court which resulted in imprisonment, probation or a fine of
more than $500? Yes or No – (Circle One) If yes, please explain.
2. Have you ever been accused of or convicted of an offense surrounding the abuse of a minor by any court,
institutional authority, or private citizen? Yes or No – (Circle One) If yes, please explain.
Skills & Training:
RA Application
1. Spoken Languages & Level (Beginner, Intermediate, Proficient): _______________________________________
_____________________________________________________________________________________________
2. Please briefly describe any experience working with diverse high school populations that you have acquired.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
3. Please briefly describe any group facilitation experience or training that you have acquired.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
4. Please briefly describe any college advising or mentorship experience or training that you have acquired.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
5. What academic skills do you feel you can help teach the high school students attending SRP?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
6. What do you hope to gain by working with TRIO Outreach this summer?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7. Have you ever assisted in supervising minors and enforcing program rules with minors? NO YES
If yes, please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
YOUR SIGNATURE CERTIFIES ALL INFORMATION PROVIDED ON THIS APPLICATION IS TRUE
AND ACCURATE TO THE BEST OF YOUR KNOWLEDGE.
SIGNATURE: ___________________________________________ DATE: _______________________
Please submit the following by April 3rd at 4pm for your Job Application to be considered:
1) A completed application 2) A current resume 3) One Letter of Recommendation (see attached form)
Submit to: Carri Fierro, TRIO Director, UCSD TRIO Outreach, Mail Code: 0341, cfierro@ucsd.edu
Building: 301 University Center, Room 125, Fax: 858-822-4132
Note: Position will be posted until filled.
UCSD TRiO Outreach Programs
Letter of Recommendation Form
UCSD TRIO Outreach Programs will host its annual Summer Residential Program from June 20th – July 24th. During
this time, 170 low-income, first generation high school youth from diverse communities will live on campus for
several weeks, taking academic courses and learning about how to be 100% college-bound. We are seeking
additional feedback about the following candidate who is applying to work with us this summer:
Name of Person Applying: __________________________________ Title of Position: _____________________
Tutors, please indicate what academic subject(s) you are applying for: ___________________________________
******************************************************************************************
To be completed by the recommender:
Your Name: ____________________________________
Title: _______________________________
Email: _______________________________________
Phone: _____________________________
Confidential faculty/staff referrals are an important part of our screening process. To the extent you are able; please
comment on the applicant’s skills, knowledge and potential, particularly in terms of working with minors from
diverse backgrounds.
1. How familiar are you with the applicant personally? (Please check all that apply)
____almost no personal contact
____many personal contacts
____very few personal contacts
_____moderate personal contact
____extensive contact with this student (know the person well)
2. Overall Evaluation of the candidate:
____Outstanding candidate
____Fair Candidate
____Strong candidate
____Poor Candidate
_____Average candidate
3. Please list and describe 3 Strengths and 3 Weaknesses that you see in this candidate:
Strengths:
Describe:
Weaknesses
Describe:
4. Do you think this person can effectively supervise minors and enforce program rules with high school
students? Please comment.
5. Please rate the following as they relate to your knowledge of the candidate:
Relevant Skills, Knowledge and Abilities
Has a strong academic background in subject area (tutor)
Can explain things clearly and effectively
Works well under pressure
Demonstrates emotional maturity
Demonstrates emotional stability
Is an excellent role model for high school students
Is comfortable with students from diverse backgrounds
Is a good listener
Can facilitate group discussions
Has energy and enthusiasm
Is flexible and can adjust well to change
Can adhere to rules and guidelines of the program
Can enforce program policies with minors
Is sensitive to others
Demonstrates multicultural awareness
Has strong interpersonal skills
Below Average
Average
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Above No
Average Basis
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6. Please comment on the 3-4 skills that you ranked the lowest and/or provide us with any additional
information about this candidate that is relevant to the position.
Thank you for your assistance in recommending this candidate!
Please return your completed recommendation form to:
Carri Fierro, UCSD TRIO Outreach, Mail Code: 0341, cfierro@ucsd.edu
Building: 301 University Center, Room 125, Fax: 858-822-4132
Note: Position will be posted until filled. Priority review given to those who apply by April 3rd at 4pm.