Greater Lakes Affiliate of College & University Residence Halls Conference Application 1
This conference takes place in Milwaukee, WI. If you have any questions please contact
Ce-Ce Brookins @ 309-438-7425
Please send a completed electronic version of your application to ARH Advisor
Ce-Ce Brookins at with the subject line: “GLACURH 2016 Conference Delegate Application” no later than 12pm on Monday, October 24, 2016
Some Information to Keep in Mind When Applying:
Activities of the conference include:
1) Networking possibilities with other student leaders.
2) Informational presentations.
3) Developing leadership skills.
4) Recognizing student leaders.
5) Fun times and memories.
Expectations of this conference will include:
1) Attending a few meetings to prepare for the conference.
2) Be ready to share information from conference.
3) Be comfortable being spirited, meeting new people, and having fun!!!
4) Working as a team from ISU and from other schools.
5) Exchanging ideas with students from all over Michigan, Ontario, Wisconsin, Illinois, and Indiana!
GLACURH 2016 November 18 – 220, 2016
Delegate Application Milwaukee, WI
Turn in by: October 24, 2016
Name: Year in School:
E-mail: Area of Campus:
Local Address: Cell Phone Number:
1. Are you currently involved with the Association of Residence Halls? (Area Government, Diversity Coalition, Floor President, etc.)
(Yes) (No)
2. What do you feel is your strongest asset and how would this be beneficial to the ISU GLACURH 2015 delegation? ______
3. Please state why you want to be selected to attend GLACURH? Please be descriptive.
______
4. GLACURH is about leadership growth and development. How do you plan to further use GLACURH as a resource?
______
5. GLACURH is about networking and you will be required to bring back ideas from other schools in addition to representing ISU in a spirited manner. How could you bring ideas back to ISU and share ideas?
______
6. The overall conference theme for GLACURH 2015 is 90s Throwback: Bringing Back Leadership. What do you think is the meaning behind this theme when it comes to leadership and residential life?
______
Emergency Contact Information
Your name: ______
Emergency Contact: ______
Relationship to you: ______
Daytime number: ______
Nighttime number: ______
Allergies: ______
Special Dietary Needs: ______
Special Accommodations Other than Food: ______
Health/Insurance Information
Name:
Permanent Address:
Permanent Phone: ( ) Age:
Date of Birth:______Last 4 digits of Social Security Number: ______
Do you have any medical/physical limitations that might hinder your participation? If yes, please describe:
Insurance Information (Please check one):
______I am covered by Illinois State University student health insurance.
______I have my own full medical insurance coverage or am covered by my parents’ or guardian’s medical
Insurance policy that I will use other than, or in addition to, Illinois State University insurance.
Primary Coverage Secondary Coverage (if any)
Carrier: ______Carrier: ______
Policy Number: ______Policy Number:______
Phone Number: ______Phone Number:______
Please list any special needs:
Access: ______
Medical: ______
Medications: ______
Allergies: ______
Dietary: ______
Emergency Information:
In case of emergency, please contact: ______Relationship:______
Home Phone: (______) ______Work Phone: (______)______
Name of Doctor: Doctor Phone: ( )
Preferred local hospital: _____ Bromenn ______St Joseph’s
If ill or injured, I give my permission for the program facilitators to render first aid, seek medical care as they see fit, and notify my emergency contact. I, ______authorize transportation to a clinic and/or hospital and/or emergency ambulatory care if necessary. I understand that I am fully responsible for the full payment of any and all bills or costs incurred by this care. I hereby release the State of Illinois, Illinois State University, its officers and its employees from any liability for medical care that may be administered.
Signed ______Date ______
RELEASE
STATE OF ILLINOIS )
) KNOW ALL MEN BY THESE PRESENTS
COUNTY OF MC LEAN )
That I, ______, do hereby release, acquit, and forever discharge The State of Illinois, Illinois State University, its officers, employees, attorneys, representatives, insurers, and assigns, each and every person, natural or corporate, from any and all demands, causes of action and/or judgments of whatsoever nature or character, past or future, known or unknown, whether in contract or in tort, whether for personal injuries, property damage, payments, fees, expenses, accounts receivable, credits, refunds, or any other monies due or to become due, or damages of any kind or nature, which have accrued, and whether arising from common law or statute, to me, my heirs, executors, legal representatives, successors or assigns, arising out of, in any way, ATTENDING GLACURH 2016 Conference.
This Release contains the entire agreement between the parties and shall be binding upon and inure to the benefit of the successors and assigns of the undersigned.
EXECUTED on this ______day of ______2016.
______
(Name)
______
Witness
Illinois State University
Personal Contract
Please read this entire document carefully before signing.
I hereby acknowledge that I understand that attendance at and travel to and from the Great Lakes Affiliate of College and University Residence Hall Conference 2016 is purely voluntary and is not a part of the academic curriculum of the University. I agree that I understand that some risk of bodily injury, property damage, and other dangers may exist.
It is expressly understood by me that I am solely responsible for any costs arising out of any bodily injury or property damage sustained through attendance at and travel to the Great Lakes Affiliate of College and University Residence Hall Conference 2016. It is my responsibility to obtain proper insurance or pay all charges associated with any injury or accident. I understand that if I am driving my own vehicle, I am doing so at my own risk. The university is not liable for any injuries or accidents that may occur.
While University employees may be accompanying the student participants on this trip, it is unlikely that those persons will be able to provide constant supervision. It is expected, however, that I will abide by university policies and regulations, the Code of Student Conduct, and all instructions presented by University staff members, whether written or verbal.
In exchange for being granted the opportunity to attend the Great Lakes Affiliate of College and University Residence Hall Conference 2016. I understand that I am expected to remain at the site and participate, to the best of my ability, in all programs, activities, and projects. I will also abide by all ground rules as expressed by the University, its representatives, and the conference organizers. Furthermore, I recognize that the University has subsidized the cost of my attendance; I will do my best to contribute to the effectiveness of the program and the well-being of the group.
As a participant, I agree to abide by the Code of Student Conduct, and understand that if I violate this code, I may be sent home at my own cost.
I have carefully read and understand completely and clearly the provisions stated above and agree to be bound thereby.
Printed Name:______
Signature:______
Date:_____ / _____ / _____
Please send a completed electronic form to Ce-Ce Brookins @ with the subject line: “GLACURH 2016 Conference Delegate Application”. Please leave signature lines blank.