SLOOP INSTITUTE FOR EXCELLENCE IN LEADERSHIP
APPLICATION
2015-2016
DEADLINE: FRIDAY, NOVEMBER 13, 2015
PLEASE RETURN APPLICATION TO CLARISSA LANG IN THE OFFICE OF LEADERSHIP AND EXPERIENTIAL LEARNING
(THE BRADDOCK HOUSE) BETWEEN 8:00 AM AND 4:00 PM
APPLICANT INFORMATION
Name:
Sex:
Email:
Date of birth:
ID #:
Cell Phone:
State:
ZIP Code:
Local address:
City:
PERMANENT INFORMATION
Address:
City:
State:
ZIP Code:
EMERGENCY CONTACT
Name:
Relationship:
Address:
City:
Phone:
State:
ZIP Code:
SCHOOL INFORMATION
Major:
Overall GPA:
# of Completed Credits:
Minor:
Anticipated Graduation Year/Semester:
Faculty/Staff Endorsement:
Faculty/Staff Email:
Faculty/Staff Phone :
ORGANIZATION INVOLVEMENT
What organizations are you currently involved with at FSU? What positions have you held or currently hold at FSU?
SIGNATURES / AUTHORIZATIONS
Authorization to Release Information: If I am selected as a Sloop Institute for Excellence in Leadership member, I authorize
Frostburg State University to release any of the above information to the public in any manner it shall choose. I also authorize the
university to verify that all the information provided on and with this application is accurate.
Electronic Signature of Applicant:
Date:
SLOOP INSTITUTE FOR EXCELLENCE IN LEADERSHIP
APPLICATION
2015-2016
SHORT ANSWER QUESTIONS
Please provide a short answer to each of the following questions regarding your leadership experience on a separate paper.
1. Choose an organization you are involved with in which you would potentially like to take on a leadership position/or already are in
a leadership position. What do you envision accomplishing for the organization with this position and how could you achieve these
goals?
2. Provide an example of a time when you stepped outside of your comfort zone. What did you learn from this experience?
3. Develop a personal mission statement and describe how you apply it at Frostburg State University.
4. Why should we choose you as a Sloop Institute Participant this year? How will you bring your experiences from Sloop back to the
campus?
Electronic Signature of applicant:
Date:
EMERGENCY CONTACT INFORMATION
(Please Print Clearly)
Date:
_____________________
Program:
Sloop Institute 2016
Participants Information:
Name: ________________________________________________________________________
Address: _______________________________________________________________________
Cell Phone #:____________________________________________________________________
Student ID #:____________________________________________________________________
Email Address: __________________________________________________________________
Emergency Contact Information:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Relationship: __________________________________________________________________
Cell Phone #: ___________________________________________________________________
Optional Information:
Dietary Restrictions (ex. Vegetarian):________________________________________________
Allergies/Reactions: ______________________________________________________________
Current Medications: _____________________________________________________________
(Please include name, dosage, and times taken.)
LIABILITY RELEASE AND WAIVER
This is a legally binding Release and Waiver executed by ______________________________. I
desire to participate in any community service opportunities or events sponsored by the Student and
Community Involvement. (“Activity”) I understand and agree that I will be transported in a University
vehicle driven by University Staff and/or a student certified driver. I fully understand and appreciate the
dangers, hazards and risks inherent in the Activity and in the transportation to and from the Activity, which
dangers include but are not limited to physical or mental injury or death.
1.
Waiver of Liability: I, individually, and on behalf of my heirs, successors, assigns and personal
representatives, hereby release and forever discharge the University, the University System of Maryland
(“USM”), the State of Maryland and its employees, agents, officers, trustees and representatives
(“Release”) from any and all liability whatsoever for any and all damages, losses or injuries (including
death), I sustain to my person or property or both, including but not limited to any claims, demands,
actions, causes of action, judgments, damages, expenses and costs, including attorneys’ fees, which arise
out of, result from, occur during or are connected in any manner with my participation in the Activity
and/or any travel incident thereto, except for such damages or injury as may be caused by the gross
negligence or actual malice of University employees, agents or representatives.
2.
Statement of Indemnification: I, individually, and on behalf of my heirs, successors, assigns and personal
representatives, hereby agree to indemnify, defend and hold harmless the University, the USM, the State of
Maryland and its employees, agents, officers, trustees and representatives (in their official and individual
capacities) from any and all liability, loss, damage or expense, including attorneys’ fees, that they or any of
them incur or sustain as a result of any claims, demands, actions, causes of action, damages, judgments,
costs or expenses, including attorneys’ fees, which arise out of, occur during, or are in any way connected
with my participation in the Activity or any travel incident thereto.
3.
Disciplinary Actions: The University reserves the right to decline to accept or retain me in the Activity at
any time should my actions or general behavior impede the operation of the Activity or the rights or
welfare of any person. Similarly, if my conduct violates the Code of Student Conduct or any policy of the
University, I understand that I may be referred to the University’s Judicial Board either during or after the
Activity and/or may be required to leave the Activity at the sole discretion of the University’s
representatives and agents.
4.
Waiver of Legal Rights: I agree that this Statement of Responsibility, Waiver, Release and
Indemnification Agreement is to be construed under the laws of the State of Maryland; and that if any
portion hereof is held invalid, the balance hereof shall, notwithstanding, continue in full legal force and
effect. By signing this document I hereby acknowledge that I have read this entire document, that I
understand its terms, that by signing it I am giving up substantial legal rights I might otherwise have, and
that I have signed it knowingly and voluntarily.
5.
I have signed this Release and Waiver in full recognition and appreciation of the dangers, hazards and risks
of such activities. I agree to report to the Director of the program any physical or mental condition I have
that may require special medical attention or accommodation at least five (5) days prior to departure. I
understand and agree that Releases do not have medical personnel available at the location of the Activity
and grant Releases permission to authorize emergency medical treatment, if necessary. I understand and
agree that Releases assume no responsibility for any injury or damage that might arise out of or in
connection with such authorized emergency medical treatment. The right is reserved by the University, in
its sole discretion, to cancel the Program or any aspect thereof if the University determines or believes that
any person is or will be in danger if the Program is continued.
_____________________________________
Participant Signature
_________________________________________
Signature of Parent
(If participant is under 18 years old)
Date:____________________________
Date: ____________________________
Frostburg State University
Office of Leadership and Experiential Learning
101 Braddock Road
Frostburg, MD 21532
VOLUNTARY PARTICIPANT RELEASE
Participant’s Name: _____________________________________________
Program:
Sloop Institute for Excellence in Leadership__________
Date(s):
Friday March 4, 2016 – Saturday March 5, 2016______
I am voluntarily participating to be photographed and allowing my
image to be used for student publications, posters, promotions and web
site designs at Frostburg State University (the “University.”)
I agree that my participation in the program confers upon me no
rights of ownership whatsoever. All materials produced pursuant to this
release may be used, in whole or in part, without inspection or further
consent or approval by me or by my parent or guardian (if applicable) of the
finished product or any use which may be made of it. I further agree that
the programs may be copyrighted, duplicated, broadcast and distributed
without limitation, through any means, now and at any time in the future.
I agree to the use of my name, likeness, voice and biographical
material about me for program publicity and promotional purposes. I
confirm that any and all material furnished by me for this program is either
my own or otherwise authorized for such use without obligation to me or
to any third party
I hereby release the University, its agents, employees, officers,
directors and assigns, from liability for any claims by me or by any third
party in connection with my participation in the above-named program.
This voluntary grant and release will not be made the basis of any future
claim of any kind against the University or the University System of
Maryland.
Signature: ___________________________ Date: ________________
Print name: _________________________________
OFFICE OF LEADERSHIP AND EXPERIENTIAL LEARNING FOR
STUDENT AFFAIRS
101 BRADDOCK ROAD
FROSTBURG, MD 21532-2303
T 301.687.7013
F 301.687.1041
Sloop Institute for Excellence in Leadership
Student Conduct Agreement
In accordance with Frostburg State University policy, I _____________________
agree to adhere to the terms and conditions listed below:
I will follow all guidelines presented in the Pathfinder. This includes behavioral
expectations and all other policies laid out within the student handbook. I am also
aware that this is a substance free conference and any behavior involving the use of
alcohol or any controlled substance is strictly prohibited. Frostburg State University is a
Smoke-Free Campus and this includes all programs and events. In addition, I
understand that failure to follow these rules may result in my immediate expulsion from
the trip.
I understand that in the event that I am expelled from the trip, I will be held
responsible for all costs including, but not limited to: travel, lodging, and food for the
duration of the trip’s planned length. In addition, all costs incurred as a result of my
expulsion (i.e. airfare, cab rides, etc.) will also become my responsibility and will be held
against my student account until paid in full. I understand that Frostburg State
University may require a judicial board hearing as a result of inappropriate behavior or
behavior inconsistent with the rules and regulations found in the Student Pathfinder
and within this agreement.
I understand that I am committing to attending the Sloop Institute for Excellence
in Leadership if selected on Friday March 4, 2016 through Saturday March 5, 2016. In
the event that I cannot attend this event, I will give the Office of Leadership and
Experiential Learning 30 day notice. In the event that it is less than 30 days before the
event, I understand that if the Office of Leadership and Experiential Learning cannot find
an alternate and fill my place, I am responsible for all costs associated with attending
this event. These costs will include but are not limited to transportation, lodging, and
meals. The estimated cost for my attendance is $340.00.
Signature: _______________________________________________________________
Printed Name: ___________________________________________________________
Date: __________________________________________________________________