Early Start Development Incorporated
6942 FM 1960 East #396
Humble, Texas 77346
281-348-2523 (fax) 281-348-2598/ www.earlystartdevelopment.org
ESD Program Application
Check all that apply: ___Quilting of the Soul
___The Writing Project
___Varsity Sports (Health, Fitness and Sports)
___STEPS (College, Leadership & Public Service)
___Career Exploration, Entrepreneurial & Service Learning
____Empowering
Girls
___Workshops/Seminars/Forums/Retreats
___College Tour/Visits Only
___ High School Leadership Empowerment Summer Retreat/Hampton University
___Youth Advisory Activity
____Youth Advisory – D.C. , MD
REQUIRED DOCUMENTS FOR APPLICATION TO BE CONSIDERED:
1.
2.
3.
Unofficial School Transcript – STEPS Program and Youth Advisory Council Annual Leadership Trip
Two References (One reference must be from a teacher, coach or school counselor) STEPS Program and Youth Advisory Trip
Completed Application and Services Requested
Annual Application Fee $25.00 (non-refundable) The application fee is for application processing only – this is not the cost of activity.
DIRECTIONS:
A.
B.
C.
Carefully read and complete this application in black or blue ink.
Please include an unofficial copy of your school transcript and reference letters – STEPS Program and Youth Advisory Trip
Mail completed application and fees to address above.
I. STUDENT DATA
NAME____________________________________________________________________________
Last
First
Date of Birth_________________
Citizenship:
Sex:
____ USA Citizenship
Middle
____Male
____Female
_____Other (Specify)____________________
Home Address_______________________________________________________________________________
Street
Apt. No.
City
State
Phone Number (_____)________________
Zip Code
Cell Number (_____)______________
Times Available for Consultation/Interview (Saturday) Indicate choices by 1-2-3: (This is only for certain programs – if
requested to do so)
____9:00a.m.
____2:00p.m.
____10:00a.m.
____3:00p.m.
____11:00a.m.
____4:00p.m.
____1:00p.m.
____5:00p.m.
Parent’s Name(s)_______________________________________________________________
Telephone Number_______________________
Cell Number_______________________
II. EDUCATIONAL DATA
Check Present Education Level
___ Elementary School 5th
___Middle School 6th or 7th
___Middle School 8th
___High School 9th
___High School 10th
___High School 11th
___High School 12th
______
___College/University
Junior/Community College
School Name___________________________________
Graduation Date_____________
If a high school senior, have you applied for financial aid?
______Yes
ACT Score
_____M _____E _____S Test Date_________
SAT Score
_____V _____M
Test Date_________
______No
Cumulative GPA_______
Counselor’s Name________________________________________
Phone (____)____________________
High School Students Only: List College(s) Applied To or Would Like to Attend (Put in order of preference)
School Name
City
State
III. EXTRACURRICULAR
All Students: Please check the activities that you are involved in at your school or community.
____Football
____Basketball
____Swimming ____Tennis
_____Debate
____Volleyball
____Soccer
____Track
_____Student Gov’t
____Cheerleader
____Orchestra/Band
____Other – Please specify____________________
____Softball
IV. EARLY START DEVELOPMENT Essay Question – STEPS Program Only
Complete questions below on a separate sheet of paper. Question and answers must be typed – double space.
I.
What are your career and educational goals? What are you doing to achieve these goals?
II.
Why are you interested in being a part of Early Start Development Program/Activities?
How did you hear about Early Start Development?
____Counselor
Referred By__________________________________________
____Teacher
____Website
School___________________________
Student Signature:________________________________________________________________________
Parent Signature:_______________________________________________________
Date:________________
Early Start Development Only
Date Received_________________________
ESD Reviewer:____________________________________
Interview Date:________________________
Accepted: _______Yes
Program Choice: #1__________________ #2___________________
References:
________Yes
________No
_______No
#3___________________
Transcripts:
__________Yes
_________No
Executive Director Signature:_________________________________________________________________
Program Activity – Student Permission and General Information Form
Please fill this form out completely. Health insurance is required even if information is already included on another form. This form must
be completed and on file at Early Start Development prior to any participation in our college tours, program activities or retreats.
V. STUDENT DATA
Participant’s Name_____________________________________________________________________
Last
First
Middle
Home Address_________________________________________________________________________________
Street
Apt. No.
City
State
Zip Code
Phone Number (_____)___________________
Cell Number (_____)_________________________
Health Insurance Co. Name________________________________________________________
Policy #____________________________________ Group ID#___________________________
Insurance Company Telephone #____________________________________________________
Parent/Guardian’s Name___________________________________________________________
Day Phone_________________________
Any allergies:
_____Yes
Is student on any medications?
Evening Phone_______________________________
_____No
Please specify if yes____________________
____Yes, specify_____________________________________
____No
PARENT PERMISSION, Release of Liability and General Information:
(1)___My child has permission to participate in the ____________________________. I understand that if he/she
does not follow the rules, regulations and instructions of the program activity coordinator, activity director, college
tour guide or the ESD staff and chaperones; he/she will be given a warning and I (the parent) will be notified
immediately. If disruption continues, I will be notified to pick up my child immediately from a designated area and
ESD staff. I will need proper identification to have my child released to me. I understand my child (the above
named participant) will only be released to only me or the person listed below as emergency contact.
Emergency Contact Name and Phone#__________________________________________________________
Cell #________________________________
Day Phone#_____________________________________
I___________________________________________(parent), have listed all known medications or allergies that
my son/daughter has as a precaution and awareness for ESD staff in case of an emergency. I give the ESD staff
permission to take my son/daughter to the nearest emergency room if an emergency occurs. I understand that an
ESD staff person will call me immediately at the onset of an emergency. I understand that my son/daughter is
responsible for his/her belongings at all times during the event.
I understand that ESD staff is not allowed to administer any medications to students other than Tylenol and only
administer if my initials is here___________. I understand that if my initials are not listed and even if I call given
permission at a later date, ESD staff will not be able to administer Tylenol for minor headaches or pain.
Students participating in an ESD event must stay on the property where the event is being held, and is not allowed to
leave the premises without proper signage out with an ESD staff member (following a workshop, seminar or
program activity). Students staying over night for an activity understand that there will be designated curfews each
evening. Students participating in retreats and tours will have strict time schedules to follow and must adhere to the
schedule and timelines set forth. If students are 15 minutes late returning to or meeting the chartered bus on the
college tour, retreat or program activity they will be given a warning. The second time this occurs a parent or
guardian will be called. If it happens a third time, the parent or guardian will have to come and pick the student up
at a designed place.
College Tours and Retreats
Early Start Development Incorporated is in the business of arranging and conducting escorted tours of college
campuses and corporate businesses for students’ higher education awareness. Early Start Development performs a
wide variety of services in connection with these tours and retreats – including college preparation camps and
workshops. Each tour group is led and supervised by an experienced Early Start Staff member and may be assisted
by one or more persons experienced in counseling or teaching high school students regarding college selection and
admissions. Early Start Development reserves the right to make any alterations in the itinerary, hotel
accommodations, transportation, food arrangements, tour leadership, cultural activity, in its sole discretion, may
deem necessary for the success of the trip. All schedules and fares quoted are based on current cost of operation,
and are subject to confirmation or adjustment before the tour departs. Additional expenses, such as student’s meals,
shall be borne by the parents or guardian.
Early Start Development Incorporated is designed to provide a stimulating and enjoyable experience for students to
compare a variety of schools and corporations under the guidance of professional educators and business leaders.
Participation in a college tour program may enhance a student’s chance of gaining admission to the college of
his/her choice.
All ESD Program Activities
ESD has a no tolerance policy on drinking, smoking, fighting, harassment, or abusive language. If any of this
occurs, a student’s parent or guardian will be called and the student maybe subjected to dismissal from the activity.
No refund will be given in this event.
I agree and consent to the ESD guidelines and agree that my child will abide by them. I also agree and consent to the
above information regarding supervision requirements for my child during this activity. I agree to indemnify and
hold harmless Early Start Development Incorporated from any claims arising out of my participation and/or my
child’s participation in the college tour, event, retreat or any programmatic activity held by this organization. I
understand by presenting my health insurance, this will be used in the event any accident happens with my child and
has to be treated at a hospital of emergency clinic. I understand, Early Start Development is not held liable for
accidents that may occur while my child is involved in an activity. However, I understand that I (the parent) will be
notified immediately if an incident occurs.
College Tour and Retreat Fees
Early Start Development Inc. fees for the college tour include: hotel lodging, campus tour, tour escort, meetings with
admission representatives, materials, cultural/historical activity, chartered bus transportation and traveling snacks on
bus ride. If I wish to cancel my reservation for a tour, I must do so in writing prior to departure. My right to refund
will depend upon the date that my written notice of cancellation is received by Early Start Development
Incorporated. If my written notice is received at least thirty-one (31) days prior to departure, then Early Start
Development will refund all of my money minus a processing fee of $75.00. If my written notice is received
between fourteen (14) and thirty-one (31) days prior to departure, Early Start Development will refund fifty percent
(50%) of the total fees charged for my college tour, minus a processing fee of $75.00. Should I cancel less than 14
days prior to the tour departure date I will not be entitled to any refund, but can request that a twenty percent (20%)
discount be applied towards another scheduled tour, retreat or other organizational activity. I understand that all
college tours depart from the Houston, TX or Humble, TX areas. In the event ESD cancels an activity due to low
enrollment, all registration fees will be refundable except the annual application processing fee ($25.00).
Other Program Fees
Early Start Development Inc. fees for other programmatic activities generally include materials for activity, t-shirt,
snack, and general application registration (which is sometimes separate from the activity fee), unless otherwise
indicated. All participants pay an annual application processing fee ($25.00). The application processing fee is not
refundable. A youth can attend as many activities as desired within the year time period by paying only one
application processing fee per year.
I agree to the rules, regulations and guidelines of the Early Start Development activity. I understand that I (the
parent) is signing this agreement because I have a child who is under the age of 18 participating in an Early Start
Development activity and/or I have a child who is still being covered by me or my spouse on life and health
insurance.
Parent or Guardian Printed Name
Parent or Guardian Signature
______________________________Date
I agree to accept responsibility for my own conduct and judgment at all times during the college tour, retreat or other
program activity held by Early Start Development Inc. I understand that Early Start Development Inc. is not
responsible for loss of valuables or loss of or damage to luggage or belongings. I specifically accept responsibility
for any financial obligations I may incur such as meals, souvenirs and for any damages or injuries I may cause,
particularly while staying on hotel property or at a college campus.
Student Printed Name
Student Signature
____________________________Date
I will be registering for the following college tour, retreat or activity:
ACTIVITY
DATE
COST
#1
#2
#3
Make the check payable to Early Start Development and remit along with all forms to the address below. An
acknowledgement will be sent upon receipt. Payment options are also available online for selected tours, retreats and
other activities. Remember: even if you pay online for an event, you still are required to send in all forms and note
payment completed online.
Mailing address:
Early Start Development Incorporated
6942 FM 1960 E. #396
Humble, Texas 77346
Fax: 281-348-2598 – Forms can only be faxed if you paid online.
Groups of 10 or more can be invoiced via email. Email: earlystartdev@yahoo.com for details.
ESD Only
Parent Permission, Release of Liability and General Information Form Received:
_____________________Date
ESD Representative Initials:___________
Signature:_______________________________________
Payment Received:
_________Yes
Check #_________
Credit Card Type: __________
Application Fee Paid: __________Yes
_________No
Amount Received:________________
Online Payment:_______Yes
____________No
________No
____________Waived
Reason waived:_______________________________________________________________________________