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July 15th-20th, 2012
Application Packet
Date: July 15th – July 20th, 2012
Office of Multicultural Affairs
269 Centennial Student Union
Mankato, MN 56001
Phone (507) 389-6300 | Fax (507) 389-1137
Office of Institutional Diversity
265 Morris Hall
Mankato, MN 56001
Phone (507) 389-6125 | Fax (507) 389-5992
www.mnsu.edu/cultdiv
A member of the Minnesota State Colleges and Universities System. Minnesota State Mankato is an Affirmative Action/Equal Opportunity University.
Individuals with a disability who need a reasonable accommodation to participate in this event, please contact Multicultural Affairs at 507-389-3500 (V),
800-627-3529 or 711 (MRS/TTY) at least 14 days prior to the event. This document is available in alternative format to individuals with disabilities by
calling the above numbers.
PROGRAM INFORMATION
WHEN:
July 15-20, 2012
Check-in: July 15, Sunday, 4pm
Check-out: July 20, Friday, 12pm
WHERE:
Minnesota State University, Mankato
Julia Sears Dormitory Complex (map included)
PROGRAM DESCRIPTION:
The Science & Engineering Summer Institute 2012 is designed to provide students of underrepresented population from
grades 6-9 an opportunity to learn about college life and the necessary preparations to be successful in college.
CURRICULUM:
- Astronomy
- Cultural geography
- Science and engineering of bridge building
- College preparedness
- Math *if schedule permits
- Robotics *if schedule permits
COST: The cost per student participant is $125* and it covers room and board, three meals a day, and access to
academic classrooms and facilities on campus. The $125 does not cover for personal laundry and purchases at vending
machines. Please make check payable to ‘Science & Engineering Summer Institute 2012’.
*Scholarships to attend the Institute are available for students who are free/reduced lunch eligible. Scholarships can
cover up to the total cost. To apply for scholarship, students must submit in addition to the application packet:


personal statement
two recommendation letters from school counselors
Personal statement and recommendation letters should be no more than 2 pages and must be in a letter format address
to ‘Science & Engineering Summer Institute Scholarship Review Committee:’ in addition to this program application.
HOW DO I APPLY?
Apply by completing the Application Packet and sign and submit all forms on the checklist.
APPLICATION PACKET CHECK LIST
[ ] Application Form with Medical Information
[ ] Liability Waiver Form
[ ] Statements from Parent(s) and Participant Form
[ ] Release Form
*For scholarship consideration, the following documents are required:
[ ] A personal statement expressing educational goals and career and aspiration
[ ] Two letters of recommendation from a counselor and/or a teacher
*Application missing any of the above documents is considered incomplete and may delay processing time.
SUBMITTING YOUR APPLICATION PACKAGE
*If you are faxing, please indicate on the cover letter, Subject: Application for Science & Engineering Summer Institute
2012
*If you are not applying for scholarship, checks should be made out to Science & Engineering Summer Institute 2012
Intercultural Student Center/Multicultural Affairs
269 Centennial Student Union
Mankato, MN 56001
(507) 389-6300
(507) 389-1137 fax
Office of Institutional Diversity
Morris Hall 265
Mankato, MN 56001
(507) 389-6125
(507) 389-5992 fax
APPLICATION FORM
Last Name:
First Name:
Home Address:
T-Shirt Size:
Ethnicity:
 Latino / Hispanic
 Asian / Pacific Islander
 African American
 Caucasian
 Native American
 Other:
 Small
 Medium
 Large
 X-Large
 2X-L
 3X-L
__________________________
School Attending & Address:
Grade:
 6th
 7th
 8th
Career Interest:
Email Address:
Cell or House Phone Number:
MEDICAL INFORMATION
Birth Date
Age:
Sex:
 Male
 Female
Medical/Health Insurance Company Name:
Weight:
Height:
Policy Number:
HEALTH HISTORY
Please answer by checking Yes or No:
Have you had a tetanus booster within the past five years?
*Please provide up-to-date immunization record.
Are there any other health or medical conditions we should be aware of?
Will you be carrying any medication?
Please write down dates, medications, dosages and anything we should know:
 Yes
 No
 Yes
 Yes
 No
 No
____________
_____
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please check any of the following that apply:
 Asthma
 Back problems
 Bronchitis
 Diabetes
 Epilepsy
 Heatstroke
 Heart condition
 Pneumonia
 Joint injuries:
___________________
 Surgery or other operations:
____________
 Allergies (e.g. drugs, insect stings, foods, etc.):
___________________
___________________________________________________________________________________________
 Conditions requiring regular medication (e.g. diabetes, epilepsy):
_____
____________________________________________________________________________________
 List any medications you are currently taking:
_____
___________________________________________________________________________________________
 Recent injuries, illnesses, operations:
____________
___________________________________________________________________________________________
 Other physical disabilities or chronic conditions:
_____
___________________________________________________________________________________________
 Emotional or behavioral disorders (e.g. phobias):
_____
___________________________________________________________________________________________
*** If any of the above are checked, please attach a document describing when you had the condition and treatment.
***
Contact Person in Emergency:
Phone(s):
If same as Parent/Guardian, leave blank.
Address:
Relationship:
Parent/Guardian Information
Parent/Guardian Name:
Address:
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Additional Contact(s) Name:
Address:
Home Phone Number:
Cell Phone Number:
Relationship to the family:
Student Signature:
Date:
_____________
Parent/Guardian Signature:
Date:
______
STATEMENTS FROM PARENT(S) AND PARTICIPANTS
FOR PARENTS:
*Please read, fill in the blank with your name and initial.
I, ________________________________, HEREBY GIVE MY PERMISSION FOR MY SON/DAUGHTER TO PARTICIPATE IN
THE SCIENCE & ENGINEERING SUMMER INSTITUTE 2012.
I UNDERSTAND THAT IF I’M NOT ABLE TO PICK UP AND DROP OFF MY SON/DAUGHTER, I WILL CALL AND INFORM THE
INSTITUTE AND HAVE WRITTEN CONSENT FOR ADULT/COUNSELOR ACTING ON MY BEHALF.________
I UNDERSTAND THAT WE ARE RESPONSIBLE FOR ADDITIONAL EXPENSES SUCH AS LAUNDRY, SNACKS,
ETC…_________
I UNDERSTAND THE VIOLATION(S) AND DISMISSAL PROCESS AND ABOUT THE $50 CUSTODIAL FEE FOR NOT PICKING UP
MY SON/DAUGHTER ON THE SAME DAY._________
FOR PARTICIPANTS:
*Please read and initial.
I HAVE READ THE PROGRAM DESCRIPTION AND UNDERSTAND MY COMMITMENT TO THIS PROGRAM AS A
PARTICIPANT._________
I UNDERSTAND THE VIOLATION(S) AND DISMISSAL PROCESS._________
Student Name:______________________________Signature___________________________Date:_____________
Parent Name:_______________________________Signature___________________________Date:_____________
RELEASE FORM
I, ________________________________________________ (Participant name) do affirm my desire to participate in the
Science & Engineering Summer Institute 2012 at Minnesota State University, Mankato.
Realizing that there is risk inherent in this activity and, in consideration of my being allowed to participate in this activity; I
personally assume all risks in connection with said activity. Such risks may include, but are not limited to travel in a
University vehicle, sporting and recreational activities, outdoor camping and unforeseen circumstances related to the
program. I further agree to release and hold harmless the State of Minnesota, the Board of Trustees of the Minnesota
State Colleges and Universities, Minnesota State University, Mankato, their officers, agents and employees from any and
all claims and liabilities of any type whatsoever and for damages to, loss or destruction of any property or injury, sickness,
or death which may now or hereinafter arise out of, result from, or in any way be connected with my participation in said
activity.
I understand that neither the State nor any of its agencies, including Minnesota State University, Mankato, provides
health insurance; it is my responsibility to obtain such insurance.
I further state that I am of lawful age and legally competent to sign this release; that I understand the terms herein is
contractual and not a mere recital; and that I have signed this document as my own free act.
I understand that a medical examination to assure myself of physical fitness is desirable, that obtaining such an
examination is my own responsibility, and assume my own responsibility of physical fitness and capacity to participate in
such event, and I am physically fit.
In Witness Whereof, I have executed this affirmation on __________________________(Date)
Student Name:______________________________Signature___________________________Date:______________
Parent Name:_______________________________Signature___________________________Date:______________
LIABILITY WAIVER FORM
To the best of my knowledge, I am in good physical condition and fully able to participate in all aspects of the Ethnic
Heritage Pre-College Summer Institute. I am fully aware of the risks and hazards connected with the participation in this
event, including physical injury or even death, and herby elect to voluntarily participate in the said event, knowing that
the associated physical activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL
RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that may be
sustained by me, or loss or damage to property owned by me, as a result of participation in this course.
I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, Minnesota State University, the Board of Trustees
of Minnesota State Colleges and University System, the Office of Institutional Diversity, the Office of Multicultural
Affairs, their officers, servants, agents, and 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, while participating in physical
activity, or while on or upon the premises where the event is being conducted.
In signing this release, I acknowledge and represent that I HAVE READ THE FORGOING Waiver of Liability and Hold
Harmless Agreement, UNDERSTAND IT AND SIGN IT VOLUNTARILY as my own free act and deed; no oral
representations, statements or inducements, apart from the foregoing written agreements have been made; and I
EXECUTE THIS RELEASE FOR FULL, ADEQUATE AND COMPLETE CONSIDERATION FULLY INTENDING TO BE BOUND BY
SAME.
Student Name:______________________________Signature___________________________Date:_____________
Parent Name:_______________________________Signature___________________________Date:_____________
SUPPLEMENTAL INFORMATION
SAFETY AND SECURITY
24 Hour Emergency Contact
Chris Tran
Interim Director of Intercultural Student Center
(507) 351-8409; christopher.tran-2@mnsu.edu
Campus Security
(507) 389-2111
Housing
All participants will reside at Julia Sears dormitories at Minnesota State University, Mankato. Only registered residents
will have access to the building entrances. Campus Security and Mankato Police patrol frequently around the University
perimeter thus all curfews will be strictly enforced.
Pick-up and Drop-off
 Only parent(s) or legal guardian(s) are allowed to pick up and drop off participants.
*Others must have written consent from parent(s) and parent(s) must notify program staff by phone.
 All participants must be picked up by 1:00pm on the day of check-out, no exception. A $50 custodial fee will be
charged to the parents for any pick-up after 1:00pm and participant(s) may not be able to return next year.
Visits
The Institute welcomes parental visit(s) at any time. Visit(s) can be arranged by calling the Intercultural student
Center/Multicultural Affairs at (507) 389-6300 and/or the Office of Institutional Diversity at (507) 389-6125.
Violation(s) and Dismissal
All participants must abide the program code of conduct. Violation(s) will be handled accordingly as followed:
 First violation will result in verbal warning.
 Second/repeated violation will result in written reprimand.
 Third violation will result in dismissal*.
Parents will be notified to pick up the dismissed participant(s) immediately. Dismissed participants must be picked up
before midnight on the same day of the dismissal decision. A $50 custodial fee will be charged to the parents for each
day passed the initial notification.
What to Bring
 Medical Information
 Toothpaste and Brush
 Bathing Soap
 Personal Items, Deodorant, etc.
 Appropriate Clothing (no halter tops or sleeveless shirts or spaghetti strap top)
 Swim Suit/Cover up
 Formal Wear (slacks, dress shirt, dresses, etc…)
Recommended Items:
 Small Fan
 Disposable Camera
 Backpack
 Pens and Pencils
 Outdoor Clothing
 Tennis Shoes
 Basketball Shoes
*Use of cell phones and other electronic devices are not allowed in the classroom unless it is classroom related.
Violation will resulted in confiscation of the device(s) for the duration of the program.