Syracuse Delegation PRHYLI Application
click here for website with required forms
Instructions:

1.
Fill out application form on-line and print it out – or - print it out and fill it in by hand.
Verify that email, emergency, cell and home phone numbers are correct.
Application must be postmarked by December 11, 2015.
Mandatory attendance is required for all five (5) trainings: Friday, January 15; Saturday
February 13; Friday, February 26; Friday, March 4; and a date in March TBD. Weekend in
Albany, Saturday March 19 – Monday March 21, 2016.

2.
Principal’s Signature on 3 forms:
3.
a.
Application Form
b.
Excused Absences Form
c.
Student Conduct Contract
Guidance Counselor’s Signature on

a.


4.
Parent(s) Signature on:
5.
a.
Excused Absences Form
b.
Photo Release Form
c.
Parental/Medical Consent Form
d.
Student Conduct Contract
Typed Essay in Spanish or English
a.

Application Form
b.
Format: Times Roman or Arial 12 font, 1” margins, double-spaced
Recommendation Forms:
a.
1st Recommendation form (given to: _________________________).
b.
2nd Recommendation form (given to: _________________________).
c.
3rd Optional Recommendation form (given to: _________________________).

c.
Most recent transcript (check with Guidance Counselor)

d.
ALL application documents must be postmarked on or before December 11, 2015
Mail to: Mid-State RBERN, Attn: PRHYLI - PO Box 4774, Syracuse, NY 13221.
Email: rbern@ocmboces.org or Fax: 315-431-8449
Note: Applications sent by email/fax will not be considered ‘complete’ until all completed documents
are received at Mid-State RBERN. Original paper copies with signatures must be received and
postmarked on or before December 11, 2015.
Applicants receive an email or text message confirming acceptance.
Angelo Del Toro Puerto Rican/Hispanic Youth Leadership Institute –
Syracuse Delegation Student Application Form 2016
Personal Data
Due by December 11, 2015
Name______________________________________________ Check one:
□ Male □ Female
Age ________
Address _____________________________________________________________________ ____________________
City _____________________________________________ NY, (Zip Code) _________________________________
Phone: (home) _________________________ (cell)_______________________ (emergency) ___________________
Email 1. _____________________________________ Email 2. _____________________________________________
Education Record
High School ________________________________________________ District ________________________________
Address ___________________________________________________________ _______________________________
City _______________________________________________, NY Zip Code _________________________________
Name of School Contact __________________________________ Contact’s phone _____________________________
Contact’s email ____________________________________________________________________________________
Check all that apply:
□11th grade
□12th grade
□ I have participated previously in PR/HYLI.
Course(s) you have taken, or are currently taking that align to the PR/HYLI Institute:
□ Participation in Government □ Economics □ US History
□ Related Electives/Please List Name(s)_________________________________________________________________
List any extra-curricular activities relevant to PR/HYLI: ____________________________________________________
_________________________________________________________________________________________________
X____________________________________
Principal’s Signature
Date __________________________
X _______________________________
Guidance Counselor’s Signature
Date ________________________
Signature verifies school’s commitment to allow student to participate in the five mandatory training sessions on Friday, January 15; Saturday
February 13; Friday, February 26; Friday, March 4; and a date in March TBD AND the statewide Hispanic Youth Leadership Institute on March 1921, 2016.
2016 APPLICATION ESSAY QUESTION
Format: Times Roman or Ariel 12 font, 1” margins, double spaced
The Hispanic Youth Leadership Institute is named in honor of Angelo del Toro. Assemblyman del Toro
captured, in his life and work, the ideals and determination that bring younger Latino/Latina leaders together in
Albany each year. The Institute is a product of his vision and energy.
This year’s theme centers on Civic Participation and Advocacy.
Angelo del Toro epitomized active civic participation and advocacy through his work in supporting children, the
elderly and the poor.
All can be inspired by Angelo del Toro’s life as an example of what is possible for those who believe in
themselves and their potential in serving their communities.
Your task:
Research Angelo del Toro
Some links to assist with your research:


http://www.prhyli.org/angelo_del_toro.php
http://www.nytimes.com/1995/01/01/obituaries/assemblyman-angelo-del-toro-47-is-dead.html?pagewanted=print
Then, write a short, concise reflection not to exceed 500 words addressing the following question:
Which qualities and leadership skills do you feel are necessary to enact positive change in your community?
Parental Consent Form and Principal’s Acknowledgement of Excused Absences
(TWO SIGNATURES NEEDED – A PARENT & PRINCIPAL’S)
Name ________________________________________________________________________________________
Emergency Contact Name _____________________________________
Phone _____________________
School ____________________________________________________
Phone _____________________
This is to certify that we the undersigned/guardians of ____________________________________ in consideration for the benefits to
be derived by our son/daughter at the PR/HYLI, do certify that he/she may participate in any normal and routine educational or
recreational programs of the PR/HYLI, hereby release and discard the NYS Education Department, Office of Bilingual Ed., Delaware
Academy, Syracuse Teacher Center and OCM BOCES Mid-State RBERN, their officers, agents, instructors and employees from any
and all illness, injury or accident occurred in or suffered by said son/daughter while traveling to, attendance at or participation in the
PR/HYLI from the time of his/her departure from home until his/her return hereto.
This will further certify that we, the undersigned parents/guardians, hereby consent and grant permission should the necessity arise, to
the furnishing of medical treatment and hospital services as ordered or recommended by a qualified physician, including the
administration of an anesthetic, laboratory procedures, medical or surgical treatment, x-ray examination, or other hospital services.
Consent is hereby granted to the attending physician(s), hospital(s), and/or clinics to release necessary information to our local doctors
and for use in claims for insurance coverage.
I also understand that my child will be required to attend a series of (4) training sessions that will take place on January 15, February
13, 26 and March 4, & TBD. In addition, I understand my child, if selected, will be leaving for Albany on March 19, at 8:00 am and
returning at approximately 4:00 pm on March 21. The adult chaperones will remain with him/her. I will make the necessary
arrangements to be on time.
Please list any medical conditions/medications/dietary needs ___________________________________
Por este medio se certifica que los padres/guardianes de ___________________ que aquí firman en consideración de los beneficios
que recibirá nuestro hijo/hija en el PR/HYLI, certificamos que él/ella puede participar en cualquier rutina educativa y recreativa del
programa. Por lo tanto, comprendemos que el Departamento de Educación de NYS, Oficina de Educación Bilingual, Academia de
Delaware, el Centro de maestro de Syracuse, OCM BOCES Mid-State RBERN, sus oficiales, agentes, instructores, y empleados no
son legalmente responsables de cualquier enfermedad o accidente causado o sufrido por mi hijo/hija mientras viaje, asista, o participe
en el programa PR/HYLI desde el momento de partida hasta su regreso.
Además, esto certifica que damos permiso, en caso de emergencia, para que se le administre ayuda médica o servicios clínicos según
sea recomendado u ordenado por un médico acreditado, incluso la administración de anestesia, exámenes de laboratorio, tratamiento
médico o quirúrgico, exámenes de rayos x, y otros servicios médicos. Se da aquí autorización al médico, hospital, y/o a la clínica para
obtener y proporcionar la información médica necesaria para completar formularios de seguros.
Además, comprendo que mi hijo/hija deberá asistir a una serie de 5 talleres de entrenamiento que se llevarán a cabo durante los días,
15 de enero, y 13 & 26 de febrero, y el 4 & ¿? de marzo, de 2016. Además, entiendo que si sea selccionado(a) la partida para Albany
será el sábado 19 de marzo a las 8:30 a.m. y que mi hijo/hija estará de regreso el lunes 21 de marzo de 2016 a las 4:00 p.m.
aproximadamente. Los chaperones esperarán con él/ella. Haré los arreglos necesarios para estar allí a tiempo. Por favor, mencione
cualquier condición física, medicamentos o necesidades dietéticas de su hijo/hija________________________________.
__________________________________________________
Parent’s Signature/Firma del padre o de la madre:
Date/Fecha
___________________________
Principal’s Signature: __________________________________ Date/Fecha _______________________________
PHOTO, VIDEO & ESSAY RELEASE FORM
We, _________________________________________________________________ (parent/guardian name) of
___________________________________________________ (student name) hereby give OCM BOCES, New
York State Education and the Puerto Rican Hispanic Task Force and their legal representatives and assigns, the
right and permission to publish, without charge, photographs, videos and essays taken during the Puerto Rican
Hispanic Youth Leadership Institute (PRHYLI) taking place March 29-21, 2016 and all PRHYLI training
sessions: January 15, February 13 & 26, March 5 & a March date TBD, 2016 (dates subject to change).
These photographs, videos and essays may be used in publication, including electronic publication, in
audiovisual presentations, promotional literature, and advertising or in other similar ways.
We hereby warrant that we are over eighteen (18) years of age, and are competent to contact in our names.
Signature(s): ________________________________________________________________________
_______________________________________________________________________
Names of Above (please print) __________________________________________________________
Month/Date/Year: _____________________________________________________________________
Address: _____________________________________________________________________________
City, State, Zip: ________________________________________________________________________
Primary contact can be reached at:
Work: __________________________________
Home: _________________________________
Disclaimer: Above information is held in confidence and is never released or sold.
6075 E Molloy Rd ▪ Syracuse NY ▪ 13221
(315) 433-2664