Leaders of Social Change
Trip Dates: December 13-18, 2014
Leaders of Social Change (LOSC), is a trip December 13th through December 18th that examines
leadership through social justice movements. This year, students and staff will tour museums,
participate in community service, engage in group activities, discussions, and reflections in the
tentative location of New York City. The activities throughout this experience will promote leadership
development, encourage constructive conversations, and motivate you to pursue your personal
passions.
Important Information:
 Participants must be current undergraduate students with at least a 2.0 GPA at all
times of the application process and at the time of the trip and be in good disciplinary
standing with the University. Graduate students are eligible to apply as Faculty
Mentors.
 If accepted, the total cost of the trip is $35. Participants may choose to pay the nonrefundable fee in two installments of $17.50 due by October 17th and November 14th
OR they may choose to pay in one installment by October17th.
 Before the trip, you will be required to attend at least 2 mandatory LOSC meetings for
participants. These days and times will be communicated via email to those who are
accepted.
 During the trip, participants will travel as a group at all times. Participants will not be
allowed to make any alternate arrangements.
 LOSC is a substance-free retreat. Use or purchase of drugs, alcohol, or anything
associated with drugs/alcohol is prohibited during the trip at ALL times regardless of
age. Participants found in violation of this policy during the trip will be sent home at
their own expense, and their names will be submitted to Community Rights and
Responsibilities.
Applications are due September 15th, 2013 @ 5:00pm
Applications can be emailed to LOSC at LeadersofSocialChange@illinoisstate.edu or dropped off at
the front desk of the Leadership and Service office, located on the second floor of the Bone Student
Center.
Participants will be notified of the status of their application by e-mail by September 29th.
For more information:
 Visit http://deanofstudents.illinoisstate.edu/involvement/leadership/programs/social/
 Email us at LeadersofSocialChange@illinoisstate.edu
 Call the Leadership and Service Unit at 309.438.7346 or stop by the office on the 2nd floor of
the Bone Student Center
KEEP THIS PAGE FOR YOUR RECORDS
This document is available in alternative formats upon request or
if you need special accommodations to fully participate in this program, please contact:
Leadership and Service, Dean of Students Office at (309) 438-7346. TTY: (309) 438-2762. Leadership.Service@IllinoisState.edu
Please allow sufficient time to arrange the accommodations.
Name:
ULID:
UID#:
-
-
Campus Address:
E-mail Address:
Phone: (
Year in school:
)
-
T-shirt Size:
Ethnicity:
Gender Identity:
How did you hear about LOSC? [Check all that apply]:
Window Banner (Bone Student Center)
Word of Mouth
Posters/Flyers
Presentation to Class or Residence Hall
Facebook
Leadership and Service Unit
Other:
Please check all of the following that you have participated in:
LeaderShape®
ASB
AWB
Club AB Weekend Trip
Leadership and Service Themed Living and Learning Community
Social Justice Institute
Honors Program
Camp Lead
Diversity Retreat
ROTC
LOSC: year
Athletic team:
RSO leadership position (specify RSO/position)
Other:
Major(s)
Minors(s)
Please list any courses that you have completed that had Social Justice or Leadership themes:
Continued on next page
This document is available in alternative formats upon request or
if you need special accommodations to fully participate in this program, please contact:
Leadership and Service, Dean of Students Office at (309) 438-7346. TTY: (309) 438-2762. Leadership.Service@IllinoisState.edu
Please allow sufficient time to arrange the accommodations.
In short paragraphs, please type your answers to the following questions on a separate sheet of paper.
Each answer should not exceed 250 words.
1. Why do you want to participate in this trip? Please tell us a little bit about why you are
applying and what you hope to gain from this experience.
2. After attending this trip, what do you plan to bring back to your campus or community? What
do you plan on doing with the information and knowledge you have gained from the trip?
3. What social justice movement(s) are you most passionate about? Also, tell us about a social
issue that you hope to learn more about.
4. Tell us about your recent experience with a social justice issue. How does this experience
affect how you see things?
**As part of the application process, you will be required to attend a group interview sometime between
the 18th of September and the 22nd of September. Please provide your availability on the following dates
and times so we are able to schedule an interview time for you. If none of these times work please
indicate that. Interviews will roughly be 30 minutes.**
Thursday the 18th from 1:30-8:00
Monday the 22nd from 1:30-8:00
Tuesday the 23rd from 12:30-2:00 or from 4:30-7:00.
COMMUNITY RIGHTS AND RESPONSIBILITIES DISCIPLINARY STANDING RELEASE:
I authorize the Community Rights and Responsibilities Office to release any confidential files or information concerning my disciplinary
record to the Leadership and Service Unit of the Dean of Students Office. I understand that this information will be requested upon
application for Leaders of Social Change.
I further understand that I must be in good standing with the University through all aspects of the program, and must notify Leadership
and Service if I lose my good standing.
SIGNATURE:
DATE:
(For applications submitted electronically, typing your name will indicate a signature)
AUTHORIZATION TO CHECK GPA:
I authorize the Leadership and Service Unit of the Dean of Students Office to check my cumulative GPA. I understand the information
will be used to confirm that I am in good academic standing (2.0 GPA, cumulative). I further understand that I must be in good standing
with the University through all aspects of the program, and must notify Leadership and Service if I lose my good standing.
SIGNATURE:
DATE:
(For applications submitted electronically, typing your name will indicate a signature)
I have read all above statements and considered them seriously. By signing below, I indicate I fully understand all
above statements, and agree to comply with them.
Signature:
Date:
(For applications submitted electronically, typing your name will indicate a signature)
This document is available in alternative formats upon request or
if you need special accommodations to fully participate in this program, please contact:
Leadership and Service, Dean of Students Office at (309) 438-7346. TTY: (309) 438-2762. Leadership.Service@IllinoisState.edu
Please allow sufficient time to arrange the accommodations.