ALTERNATIVE BREAKS @ UCSD
2015 - 2016 Participant Application
NAME:
PRIMARY E-MAIL:
PID:
PHONE:
YEAR/CLASS STANDING:
BIRTH DATE (MM/DD/YY):
COLLEGE:
PAST AB GROUP(S) AND YEAR (if any):
MAJOR(S)/MINOR(S):
FOREIGN LANGUAGES (if any):
T-SHIRT SIZE:
GENDER IDENTITY:
ALLERGIES:
DIETARY RESTRICTIONS:
Are you a U.S. Citizen or permanent resident? Yes _ No ___
If No, what is your immigration status_____________ (This information is for planning and logistical
purposes and will not be used as a criterion for the program provided that it is legal for you to travel.)
Page 1
Participant Application Process
Please read carefully to ensure the correct completion and submission of your application. Each step in this
process is required.
●
●
●
●
●
●
Attend at least ONE 30-minute Info Session.
Attend the AB@UCSD Trip Reveal on Wednesday, October 21st, 2015 (5:30 - 9:30 pm) in
the Dolores Huerta/Philip Vera Cruz Room (Old Student Center).
o Meet the Service Leaders and learn about their community partner and social justice issues.
o Attending this event is mandatory but you will not need to stay for the whole time.
Complete this Alternative Breaks Participant Application Form.
o This form must be submitted via email by Thursday, October 22nd, 2015 at 11:59pm to the
Service Leaders of the group(s) that you choose to apply for.
o After submitting your application you will receive a confirmation email from the Service
Leaders, which will include a link to sign up for an interview time slot.
o Closely follow the submission process listed in the next section.
Sign up for a group interview.
o Please provide a class/work schedule for Fall 2015 (and Winter 2016, if possible) at each
interview.
Attend your group interview(s).
o You will hear back from the Service Leaders by Friday, November 6th.
If accepted, you must attend the mandatory Fall Orientation held on Saturday, November 7th.
o If you are unable to attend, please indicate why: _____________________________
Submitting Your Application
Electronic Application
1. Download this file as a Microsoft Word Document.
2. Fill out the application according to the directions listed in each section.
3. Once you have finished, save the file as a single PDF titled:
<FIRSTNAME> <LASTNAME> Application
a. Example: Jamie Doe Application
b. Under “File” click “Save As,” then select “PDF” for “Save as type”
4. Email the saved PDF to the Service Leaders whose group(s) you apply for with the subject line
“Participant Application: FirstName LastName”.
a. Example: Participant Application: Jamie Doe
b. Service Leaders’ email addresses can be found below each trip blurb at
http://www.alternativebreaksatucsd.org/spring-trips.html
Interview Sign Up
1. After submitting your application, the group’s Service Leaders will send a link to you to sign up for a
group interview time. You must submit your application before signing up for a group interview.
2. Sign up for one time slot per group you are applying for. Remember, you can apply to a maximum of
two groups.
3. Sign up for interviews ASAP but no later than Friday, October 23 at 11:59pm.
**This is an initiative by AB@UCSD to be environmentally classy and save A LOT of paper ☺**
Page 2
Pertinent Information
Please read carefully the following lines for pertinent information as a participant in the Alternative Breaks @
UCSD application process.
●
Go here for the list of AB trip titles and social justice issues:
http://www.alternativebreaksatucsd.org/spring-trips.html
●
There is a non-refundable $60 AB@UCSD Collaborative due to be turned in at Fall Orientation if
accepted into an AB group. The money will go toward paying for collaborative events for you, the
participants. An approximate breakdown of costs, based on last year’s, is below.
Fall Orientation
$4.00
Winter Retreat
$30.00
Spring Reorientation
$8.00
T-Shirt
$8.00
Benefit Dinner
$10.00
TOTAL
$60.00
●
Alternative Breaks@UCSD Student Scholarship Application
○ Please note that scholarship information and applications will be discussed and released during
Fall Orientation.
●
If you apply to 2 groups, you will be able to rank your preference during your second group interview.
Your Service Leader pairs will remind you of this immediately after your interview.
●
If you have any questions about the application process please feel free to e-mail us at
abatucsd@gmail.com.
Page 3
Participant Commitments
Please initial in the space provided indicating that you understand the minimum commitments of being a
member in a group as part of Alternative Breaks @ UCSD. Please carefully read each section before initialing.
Alternative Breaks @ UCSD General Commitment _______ (initial here)
● By initialing here, you understand that this is a year-long commitment, from the time of acceptance into
a group to the end of Spring Quarter.
● If accepted, you are committed to the responsibilities of the group that you get accepted to, which
includes financing your trip costs, participating in group meetings, completing pre- and post-trip
projects, attending group events such as volunteering, etc.
Time Commitment _______ (initial here)
● Weekly Group Meetings (~1.5-2 hours in length, chosen at the convenience of group participants)
● Quarterly Retreats
o Fall Orientation: Saturday, November 7th (on campus)
o Winter Retreat: January (one Saturday & Sunday, on & off campus, overnight)
o Spring Reorientation: April (one Saturday & Sunday, on campus, not overnight)
● Spring Benefit Dinner (one evening on a weekend at the end of April)
● Participation with group-specific fundraisers
● Assist in collaborative efforts
Alternative Breaks @ UCSD Learning Outcomes Assessment _______ (initial here)
● ALL participants are required to participate in the Learning Outcomes Assessment to provide data to
ensure the continual improvement of the quality of our program for the participant experience. At a
minimum, participants will be required to fill out these brief, online surveys:
o Pre-Assessment: November 2015
o Mid-Assessment: March 2016
o Post-Assessment: April/May 2016
o (OPTIONAL) Year-After Assessment: November 2016
● There also will be other optional forms of assessment such as focus groups, interviews, etc.
Alternative Breaks @ UCSD Judicial Form _______ (initial here)
● ALL participants are required to complete the Judicial Form to inform AB@UCSD of your student
conduct history. The form is at the end of this application, which you must electronically sign to give
consent to have your judicial history reviewed. If you refuse to give consent, you will not be allowed to
participate in AB@UCSD.
Alternative Breaks @ UCSD Collaborative Financial Policy _______ (initial here)
● ALL participants are required to submit a $60 due to participate in the program. This will go directly
toward quarterly retreat costs, t-shirts, and Benefit Dinner, and will be managed by the Finance Chairs.
Please note that this $60 program fee is non-refundable should you decide to drop from the program
at any point. By initialing, you agree to pay this $60 which will be due at Fall Orientation.
Alternative Breaks @ UCSD Group Fundraising Events _______ (initial here)
● Each AB group will coordinate fundraisers. Each participant must help and support in the various
group fundraising events. This includes, but is not limited to, individual group fundraisers coordinated
by your Service Leaders, marketing & selling of Collaborative fundraising tickets, attending
Collaborative fundraisers, etc.
Page 4
Personality Map
Please highlight the number that best fits you on each scale. Use your best judgment and be as
truthful as possible. We are trying to create balance in our groups and do not prefer one
characteristic to the other, but see the potential and value in diversity.
I tend to/I am often…
Go along
Quiet
Supportive
Compliant
Ask questions
Cooperative
Shy
Introverted
Slow and studied
Reserved
Calm
Inhibited
Task-oriented
Serious
Attend to many details
Talk only business
Want facts
Forget to follow up
Imperceptive
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
Take charge
Talkative
Challenging
Assertive
Make statements
Competitive
Outgoing
Extroverted
Fast-paced
Open
Excitable
Animated
People-oriented
Fun-loving
Focus on the big picture
Share personal feelings
Want opinions
Forget to start
Sensitive
Reference Information
● Identify one person who may be contacted in reference to your application. The reference can
be a friend, co-worker, professor, employer, etc. — someone who knows your personality, your
strengths and weaknesses, how you function in group settings, etc.
Reference may not be a family member.
● Before listing someone as a reference, it is courteous to contact that person to secure his/her
permission to serve as a reference for you. Please verify current contact information and tell
him/her a little about the participant application.
Reference Name: _______________
Relationship to you: __________________
E-mail: ______________________
Phone: ___________________________
Page 5
Free Response Section
Please keep your answers concise and relevant. Simply place your responses after each respective
question. There are no right or wrong answers to these questions, so please answer honestly and
true to yourself rather than what you think others would want to hear.
1)
Have you ever volunteered before?
If yes, then please describe your single most impactful volunteer experience.
If no, what makes you want to volunteer now?
2)
What are some of the reasons that you want to go on an Alternative Break? If you are a
returning Breaker, please also mention why you want to reapply.
3)
What social justice issues are you most passionate about and why? Examples are listed below.
●
●
●
●
●
●
●
●
Affordable Housing
Agriculture
Children and Youth
Community Development
Cultural Issues
Disaster Relief
Domestic Violence
Education
●
●
●
●
●
●
●
●
Elderly Issues
Environment
Food Justice
Health/Mental Health
HIV/AIDS
Hunger/Homelessness
Immigration Issues
Law/Government/Politics
●
●
●
●
●
●
●
●
Mental Health
Migrant Farmworker
Native Americans
Natural Conservation
People with Disabilities
Rural/Urban Poverty
Women’s Issues
Others:
4)
What are some of your interests and/or hobbies outside of your coursework?
5)
How do you think others perceive you?
6)
Please describe something unique about your background or personality that you can bring as
an individual to your Alternative Breaks group.
7)
What song best describes your personality?
8)
How did you hear about Alternative Breaks@UCSD?
9)
Please list out your current weekly commitments (e.g. academics - 10hrs; work - 10 hrs; other
student orgs - 6 hrs; etc.)
Page 6
Page 7
Student Judicial Affairs Form
Alternative Breaks@UCSD
Your College Dean of Student Affairs or designee of the Dean of Student Affairs must complete
this form and return it to Ryan Crawford, Community Service Program Coordinator, at the UC San Diego
Center for Student Involvement, mail code 0078. Your signature provides consent for release of this
information from the point of the application until the starting date of the trip. If you have been sanctioned at
any time after the initial review of your judicial history, it is your responsibility to communicate this information
in a timely manner to the Community Service Program Coordinator. Thank you for your assistance with this
request. Note: you must only complete the “COMPLETED BY STUDENT” section; leave the rest of this page
and the next page of this application blank.
COMPLETED BY STUDENT
Student’s Printed Name:
PID:
Student’s Electronic Signature:
College:
COMPLETED BY UNIVERSITY
To the Dean of Students or designee of the Dean of Students: The student named above has applied to
participate in an Alternative Breaks@UCSD Spring or Summer Break Trip. We would appreciate a confidential
statement evaluating this student’s record at UC San Diego. While prior disciplinary history does not preclude a
student’s participation, this information is taken into consideration during the application review and must be
submitted in order for the student to be evaluated for the program. Should a student’s status change from the
time of completion of this form until departure, we would greatly appreciate notification of any significant
changes to this record. Please return this form within three working days of receiving it to Ryan Crawford,
Community Service Program Coordinator, mail code 0078.
_______ This student has not received a judicial sanction at this institution.
_______ This student is not currently under an active judicial sanction but has been previously sanctioned for:
_____________________________________________________________________________________
Violation/adjudication date
Sanction with effective dates
_____________________________________________________________________________________
Violation/adjudication date
Sanction with effective dates
_____________________________________________________________________________________
Violation/adjudication date
Sanction with effective dates
_____________________________________________________________________________________
Violation/adjudication date
Sanction with effective dates
Page 8
_______ This student is currently under the following judicial sanctions:
_____________________________________________________________________________________
Violation/adjudication date
Sanction with effective dates
_____________________________________________________________________________________
Violation/adjudication date
Sanction with effective dates
_____________________________________________________________________________________
Violation/adjudication date
Sanction with effective dates
Additional Comments
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Certification - Dean of Students or Designee of the Dean of Students, please sign below to certify that the
above information is correct to the best of your knowledge.
_____________________________________________________________________________________
Your printed name
Title
_____________________________________________________________________________________
College/Department
Contact Phone Number
_____________________________________________________________________________________
Signature
Date
Dean of Student Affairs or Designee of the Dean of Student Affairs,
Please return all materials to:
ATTN: Ryan Crawford
UC San Diego Center of Student Involvement
9500 Gilman Drive # 0078
La Jolla, CA 92093-0078
Phone: 858-822-4762
E-mail: rcrawford@ucsd.edu
Website: http://getinvolved.ucsd.edu/
Page 9
I state that all the information in this application is correct to the best of my knowledge. I agree to abide by
all policies set forth by Alternative Breaks @ UCSD as explained in this application and at the Information
Sessions. I agree to not disclose any information pertaining to the interviews with any other applicants until
after the selection process is complete and notifications have been sent out.
PRINT NAME HERE: _______________________
DATE: _________________
Thank you so much for applying to Alternative Breaks @ UCSD.
We, the Alternative Breaks @ UCSD Leadership Team,
look forward to seeing you at Trip Reveal!
Page 10