Brought to you by the Center for Civic Engagement
at the University of Texas at El Paso
www.utep.edu/cce
CYnergy Fellowship Application
Contents
o
o
o
o
o
o
o
Letter to Prospective Fellow
CYnergy Fellowship Information Sheet
Application Instructions
Application Form
Letter of Recommendation Form (2)
Release and Indemnification Agreement Form
Challenge Course Release form
Send to: Center for Civic Engagement, 500 W. University Ave. Benedict Hall Rm. 101, El Paso, TX
79968
February 09, 2009
Dear Prospective Fellow,
It is with great pleasure that we take this opportunity to introduce to you the CYnergy Fellowship for
Progressive Civic Leaders of Tomorrow under the Center for Civic Engagement at the University of Texas at
El Paso. This Fellowship is a great opportunity for students, such as yourself, to engage in progressive
leadership training while making a difference, not only in your life, but in the lives of others.
As a young leader, you must be equipped with the proper tools to become civically responsible young adults
for the advancement of society as a whole. Today more than ever, society looks upon the youth to create
and mobilize change, but all too often, teens are unaware of the problems facing society and feel powerless
to enact positive solutions to those challenges.
Today we call upon you to take charge and create action! Join the CYnergy Fellowship to embark on a
weeklong training that will fuel your passion and give you the tools necessary for a deeper understanding of
civic participation, progressive leadership, and community awareness. You will be provided the tools and
skills that are necessary to spread a wave of energy across campuses and those people around you for the
betterment of a democratic society.
As the next generation of CYnergy Fellows, you will acquire the knowledge and skills necessary to become
great leaders and make a difference in both our community and our world. We look forward to receiving
your application and learning more about your interests and talents!
Best Wishes,
Jennifer Rodriguez
Program Coordinator
CYnergy Fellowship
Thanks to our program sponsor
State Farm®
Center for Civic Engagement ● University of Texas at El Paso
500 W. University Ave ● Benedict Hall, Room 101 ● El Paso, TX 79968
Ph (915) 747-7969; Fax (915)747-8917
cce@utep.edu ; www.utep.edu/cce
Join the CYnergy
Fellowship!
Brought to you by the Center for Civic
Engagement at UTEP with support from
State Farm®
All across America the movement to mobilize, encourage, and inspire young leaders has taken the country by
storm. The Center for Civic Engagement has joined this progressive force to bring a new wave of energy to El
Paso through the CYnergy Fellowship.
What does the fellowship consist of?
The program consists of an intensive week of training on progressive civic leadership. The fellowship
emphasizes the importance of civic awareness and action within the young adult population. The
Fellowship training is structured in a cohesive four-phased configuration: Power, Awareness, Tools and
Action. Students have the opportunity to participate in ropes courses, progressive leadership training,
planning, as well as visiting with community leaders and organizations.
When and where does the training take place?
The training takes place at the University of Texas at El Paso during the summer starting on Sunday, June
14th through Saturday June 20th, 2009. Admitted Fellows are provided with room and board at the Miner
Village Residence Halls through the entire training.
What happens after the training?
CYnergy Fellows go back to their high schools as juniors and seniors to raise a campaign of action. Fellows
motivate students on their campus to address a challenge faced by their community, and throughout the
year meet with the Center for Civic Engagement to begin the development and implementation of their
designed CYnergy project.
How do I apply?
Faculty and staff at your campus may have application packets available for you. You may also download
the packet from our website (please click link below). The Center for Civic Engagement will only choose 2530 applicants, as space is limited. Applications are due by 5:00pm on Friday, April 17, 2009 at the office
of the Center for Civic Engagement (UTEP- 500 W. University, Benedict Hall Rm 101, El Paso, Texas
79968). Once you’ve submitted your application, we may contact you to set up an interview for either
Saturday, April 25th or Saturday, May 2nd.
Who may apply?
This program is offered to incoming juniors and seniors attending any El Paso County high school.
Students from El Paso area high schools will be selected by the CYnergy Selection Committee. The
selection of the top candidates from each school will be based on the students’ demonstration of the
following six criteria: social consciousness, organizational skills, progressive leadership, academic
achievement, ability to work with others and analytical reasoning.
For more information you may contact the Center for Civic Engagement at UTEP at (915) 747-7969 or via e-mail
cce@utep.edu. You may also log on to our website www.utep.edu/cce
Application Instructions
We congratulate you for making the decision to apply for the 2009 CYnergy Fellowship. It is very important that
you complete your application and to do so, here are the instructions and checklist.
□ Eligibility:
□ Classification: Upcoming Junior and Senior students that attend any El Paso county high school□ GPA: 2.0/4.0 or (75/100)
□ Time commitment:
o Participate in an interview with CYnergy Selection Committee on either April 25th or May 2nd
o Parent Orientation on May 27th, at 7:00pm- Place to be announced
o CYnergy Week: June 14th-June 20(in house/miner village)
o Fall meetings
o Spring celebration
o Creation of a year-long service-learning project
□ Application (provided) - Complete 2009 CYnergy Fellowship Application and the emergency
contact information.
□ Resume- Include your current resume of any achievements, awards and education. Be sure to list any
volunteer service you may have completed.
□ Two letters of recommendation (provided)- The Letter of Recommendation sheets need to be completed
and attached to a separate letter of recommendation that answers the four questions in the sheet about
you.
□ Personal statement- Describe the world around you—for example, your family, community or
school—and how this world has shaped your progressive leadership mindset. Include examples
that demonstrate how you possess the following qualities:
 Community mindedness
 Organizational skills
 Academic Achievement
 Analytical skills
 Team work ethics
Personal statement must be submitted in any of the following forms:
 Video (VHS, DVD or MiniDV)
(minimum 5 minutes / maximum 10 minutes – your high school’s media room may be helpful)
 Written essay (minimum: 2 pages / maximum: 5 pages – DS/12pt/TNR)
□ High school transcript- Your unofficial or official transcript is necessary to verify academic standing.
□ Release and Indemnification form (provided)- Your parent/guardian MUST sign the form in order to
consider your application valid.
□ Challenge Course Release form (provided)- Your parent/guardian MUST sign this form as well in order
participate in the Ropes Courses.
Applications must be submitted as a complete packet in a clasp folder. Incomplete applications will NOT be considered. If you
have any questions, you may contact the Center for Civic Engagement at (915) 747-7969 or via e-mail at cce@utep.edu
2009 CYnergy Fellowship Application Form
Name:
______________________________________________
Last
First
Middle Initial
Address: ______________________________________________
Number, Street, Apartment Number
_______________________________________________
City
State
Date of Birth: ___/___/___
Zip Code
Telephone Number: (
)______________
Email Address:_______________ Cell Phone Number: (
)______________
High School : _____________________________________________
GPA: ___________
Gender: Male_______ Female______
Emergency Contact
Name: ________________________________________________
Last
First
Middle Initial
Relationship:_____________________________________________
Address:_______________________________________________
Number, Street, Apartment Number
________________________________________________
City
Work Phone: (
State
)______________
Cell Phone Number: (
Zip Code
Home Phone: (
)______________
)______________
Center for Civic Engagement ● University of Texas at El Paso
500 W. University Ave ● Benedict Hall, Room 101 ● El Paso, TX 79968
Ph (915) 747-7969; Fax (915)747-8917
cce@utep.edu ; www.utep.edu/cce
Letter of Recommendation
The CYnergy Fellowship emphasizes the importance of civic awareness in the young adult
population. The fellowship helps build character by giving today’s youth an appreciation of and
passion for civic engagement, inspiring them to examine previously unnoticed avenues for social
change. Through effective training and leadership development, the program provides the
opportunity for these young adults to take the knowledge acquired back to their campuses, and use
their energy to create effective civic action. CYnergy Fellows are selected based on their
demonstration of the following characteristics: community mindedness, organizational skills,
progressive leadership, academic achievement, ability to work well with others and analytical
reasoning.
Name of Nominee: ________________________________________________________________
Your Name: ________________________________Telephone:_____________________________
Title: ____________________________________________________________________________
Address: ________________________________________City:______________State:__________
□
I recommend the above referenced student to be a fellow of the CYnergy Fellowship of 2009.
Signature: __________________________________________________
Please respond to the four questions asked below on a separate letter of recommendation. Sign
the completed form and attach to the letter of recommendation, and return it to the student in a
sealed envelope with your signature on the back flap of the envelope. The student will submit your
letter of recommendation with his/her application packet.
1. Please provide the applicants full name. How long you have known the applicant and in
what capacity?
2. What are the applicant’s major strengths and abilities? Please cite specific examples in
which these abilities were displayed.
3. What are the applicant’s areas of improvement and development? How would this fellowship
serve to heighten those qualities?
4. Please describe the applicant’s distinguished characteristics? (i.e. evidence of community
mindedness, organizational skills, leadership, academic achievement, analytical skills, ability
to relate to others, motivation, etc.)
If you have any questions regarding this recommendation please contact the Center for Civic Engagement
at (915) 747-7969 or via e-mail cce@utep.edu. For more information you can also visit our website at
www.utep.edu/cce
Letter of Recommendation
The CYnergy Fellowship emphasizes the importance of civic awareness in the young adult
population. The fellowship helps build character by giving today’s youth an appreciation of and
passion for civic engagement, inspiring them to examine previously unnoticed avenues for social
change. Through effective training and leadership development, the program provides the
opportunity for these young adults to take the knowledge acquired back to their campuses, and use
their energy to create effective civic action. CYnergy Fellows are selected based on their
demonstration of the following characteristics: community mindedness, organizational skills,
progressive leadership, academic achievement, ability to work well with others and analytical
reasoning.
Name of Nominee: ________________________________________________________________
Your Name: ________________________________Telephone:_____________________________
Title: ____________________________________________________________________________
Address: ________________________________________City:______________State:__________
□
I recommend the above referenced student to be a fellow of the CYnergy Fellowship of 2009.
Signature: __________________________________________________
Please respond to the four questions asked below on a separate letter of recommendation. Sign
the completed form and attach to the letter of recommendation, and return it to the student in a
sealed envelope with your signature on the back flap of the envelope. The student will submit your
letter of recommendation with his/her application packet.
1.
2.
3.
4.
Please provide the applicants full name. How long you have known the applicant and in
what capacity?
What are the applicant’s major strengths and abilities? Please cite specific examples in
which these abilities were displayed.
What are the applicant’s areas of improvement and development? How would this
fellowship serve to heighten those qualities?
Please describe the applicant’s distinguished characteristics? (i.e. evidence of community
mindedness, organizational skills, leadership, academic achievement, analytical skills,
ability to relate to others, motivation, etc.)
If you have any questions regarding this recommendation please contact the Center for Civic Engagement
at (915) 747-7969 or via e-mail cce@utep.edu. For more information you can also visit our website at
www.utep.edu/cce
RELEASE AND INDEMNIFICATION AGREEMENT
(Minor Student Participant)
Participant: (Name and Address)
University:
The University of Texas at El Paso
Department: Center for Civic
Engagement
Description of Activity or Trip:
CYnergy Fellowship under the Center for Civic Engagement. Will be traveling to and from
Community sites in the El Paso County area.
Location:
UTEP and various community sites
Date(s):
6/14-6/20 2009
I am the Parent/Guardian of the above-named Participant who is under eighteen years of
age and am fully competent to sign this Agreement.
I give permission for Participant to participate in the above-referenced Activity or Trip. I
acknowledge that the nature of the Activity or Trip may expose Participant to hazards or
risks that may result in Participant’s illness, personal injury or death and I understand and
appreciate the nature of such hazards and risks.
In consideration of Participant being permitted to participate in the Activity or Trip, I
hereby accept all risk to Participant’s health and of his/her injury or death that may result
from such participation and I hereby release the University of Texas at El Paso, its
governing board, officers, employees and representatives from any liability to Participant,
Participant’s personal representatives, estate, heirs, next of kin, and assigns for any and
all claims and causes of action for loss of or damage to Participant’s property and for any
and all illness or injury to Participant’s person, including Participant’s death, that may
result from or occur during Participant’s participation in the Activity or Trip, whether
caused by negligence of the University, its governing board, officers, employees, or
representatives, or otherwise. I further agree to indemnify and hold harmless the
University and its governing board, officers, employees, and representatives from
liability for the injury or death of any person(s) and damage to property that may result
from Participant’s negligent or intentional act or omission while participating in the
described Activity or Trip.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO
BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR
PARTICIPANT’S INJURY OR DEATH OR DAMAGE TO PARTICIPANT’S
PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED
ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES
NAMED AND FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY
PERSON AND DAMAGE TO PROPERTY CAUSED BY PARTICIPANT’S
NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
_____________________________________________ Date:
Signature of Parent/Guardian
_____________________________________________
Address, if different than Participant’s
_________________
_____________________________________________ Date:
Witness
_________________
Challenge Course Participant Information and Release Form
DISCLOSURE:
UTEP CHALLENGE COURSE PROGRAMS INVOLVE A VARIETY OF ACTIVITIES THAT OFTEN INCLUDE WARMUPS, GAMES, GROUP INITIATIVE PROBLEMS, HIGH AND LOW ROPES COURSE ELEMENTS, AND OTHER PHYSICAL
ACTIVITIES. THE LEVEL OF PARTICIPATION IN A CHALLENGE COURSE ACTIVITY IS AT ALL TIMES
COMPLETELY VOLUNTARY AND UP TO THE INDIVIDUAL’S CHOICE. YET THERE IS A RISK, WHICH MUST BE
ASSUMED BY EACH PARTICIPANT, THAT HE OR SHE MAY SUFFER AN EMOTIONAL OR PHYSICAL INJURY OR
DISABILITY.
PLEASE PRINT
Participant’s Name:
Age:
Address:
Home Phone:
City:
Zip:
Business:
Do you have any health problems or disability that may affect your ability to participate in the UTEP
Challenge Course Program? If yes, please explain:
RELEASE/WAIVER: IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE AS DESCRIBED ABOVE, I
RELEASE FOR MYSELF AND MY PERSONAL REPRESENTATIVES, HEIRS AND NEXT OF KIN, FOR ALL LOSS OF
DAMAGE, AND FROM EVERY CLAIM, DEMAND, ACTION OR RIGHT OF ACTION, OF WHATSOEVER KIND OR
NATURE EITHER IN LAW OR IN EQUITY, ON ACCOUNT OF INJURY TO PERSON OR PROPERTY, OR RESULTING IN
DEATH, WHETHER CAUSED BY THE NEGLIGENCE OF UTEP OR OTHERWISE WHILE PARTICIPATING IN THE
ACTIVITY DESCRIBED ABOVE.
INDEMNITY: I AGREE TO INDEMNIFY UTEP AND ALL REPRESENTATIVES OF UTEP FROM ANY LOSS,
LIABILITY, DAMAGE OR COST THAT MAY INCUR DUE TO MY PARTICIPATION, WHETHER CAUSED BY THE
NEGLIGENCE OF UTEP OR OTHERWISE.
I EXPRESSLY AGREE THAT THIS RELEASE, WAIVER AND INDEMNITY AGREEMENT IS INTENDED TO BE AS
BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE OF TEXAS AND THAT IF ANY PORTION OF
THIS AGREEMENT IS HELD INVALID, IT IS AGREED THAT THE BALANCE SHALL, NOTWITHSTANDING, CONTINUE
TO FULL LEGAL FORCE AND EFFECT.
THIS RELEASE CONTAINS THE ENTIRE AGREEMENT BETWEEN MYSELF AND UTEP AND THE TERMS OF THIS
AGREEMENT ARE CONTRACTUAL AND NOT A MERE RECITAL.
Print Name:
Signature:
Date:
MUST BE COMPLETED BY PARENT / GUARDIAN IF PARTICIPANT IS UNDER 18
Parent / Guardian Print Name:
Parent / Guardian Signature:
Created 7/2002
Date: