Leaders of Social Change
Trip Dates: December 12th-17th, 2015
Leaders of Social Change (LOSC) is a trip December 12th through December 17th that examines leadership through social justice movements. This year, students and staff will tour museums, participate in community service; engage in group activities, discussions, and reflections in the location of Birmingham, Alabama. The activities throughout this experience will promote leadership development, encourage constructive conversations, and motivate you to pursue your personal passions in being an agent of social change.
Applications are due September 11th, 2015 @ 5:00pm
Applications can be emailed to LOSC at or dropped off at the front desk of the Leadership and Community Connections, located on the second floor of the Bone Student Center.
Participants will be notified of the status of their application by e-mail by September 29th.
For more information:
· Visit http://deanofstudents.illinoisstate.edu/involvement/leadership/programs/social/
· Email us at
· Call the Leadership and Community Connections Unit at 309.438.7346 or stop by the office on the 2nd floor of the Bone Student Center
Name: ULID: UID#: - -
Campus Address:
E-mail Address: Phone: ()-
Year in school:
Ethnicity: Gender Identity:
How did you hear about LOSC? [Check all that apply]:
Posters/Flyers/Handout Social Media
Leadership and Community Connections Unit Festival ISU
Word of Mouth Presentation to Class/Residence Hall/RSO Other:
Please check all of the following that you have participated in:
LeaderShape® ASB AWB Club AB Weekend Trip Camp Lead
iQuest ROTC ISULeads
Leadership and Service Themed Living and Learning Community LOSC: year
Social Justice Institute Honors Program Athletic team:
RSO leadership position (specify RSO/position)
Other:
Major(s)
Minors(s)
Please list any courses (or extracurricular activities) that you have completed that had Social Justice or Leadership themes:
This document is available in alternative formats upon request or
if you need special accommodations to fully participate in this program, please contact:
Leadership and Community Connections, Dean of Students Office at (309) 438-7346. TTY: (309) 438-2762.
Please allow sufficient time to arrange the accommodations.
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In short paragraphs, please type your answers to the following questions on a separate sheet of paper.
Each answer should not exceed 250 words.
1. Why do you want to participate in this trip? Please tell us a little bit about why you are applying and what you hope to gain from this experience.
2. Tell us about your recent experience with a social justice issue. How does this experience affect how you see things?
3. What social issues do you hope to learn more about as a participant of the trip and why?
4. After attending this trip, what do you plan to bring back to your campus or community? What do you plan on doing with the information and knowledge you have gained from the trip?
**As part of the application process, you will be required to attend a group interview (roughly 30 minutes) sometime between September 14th-23rd. Please come to the Leadership and Community Connections Office on the second floor of the Bone Student Center to write your name and reserve your time. There will be a clipboard with these times on the front desk. If none of these times work please indicate that..**
Monday September 14th & 21st : 7-9am, 12-3pm, 5:30-6pm
Tuesday September 15th & 22nd : 7-9am, 5-7pm
Wednesday September 16th & 23rd : 7-9am, 3:30-5:30pm
Thursday September 17th: 7-9am, 3:30-5:30pm
Friday September 18th: 12:30-5pm
Saturday September 19th: 9-4:30pm
Student conduct and conflict resolution:
I authorize the Student Conduct and Conflict Resolution to release any confidential files or information concerning my disciplinary record to the Leadership and Community Connections Unit of the Dean of Students Office. I understand that this information will be requested upon application for Leaders of Social Change.
I further understand that I must be in good standing with the University through all aspects of the program, and must notify Leadership and Community Connections if I lose my good standing.
Signature: Date:
(For applications submitted electronically, typing your name will indicate a signature)
Authorization to Check GPA:
I authorize the Leadership and Community Connections Unit of the Dean of Students Office to check my cumulative GPA. I understand the information will be used to confirm that I am in good academic standing (2.0 GPA, cumulative). I further understand that I must be in good standing with the University through all aspects of the program, and must notify Leadership and Community and Connections if I lose my good standing.
Signature: Date:
(For applications submitted electronically, typing your name will indicate a signature)
I have read all above statements and considered them seriously. By signing below, I indicate I fully understand all above statements, and agree to comply with them.
Signature: Date:
(For applications submitted electronically, typing your name will indicate a signature)
This document is available in alternative formats upon request or
if you need special accommodations to fully participate in this program, please contact:
Leadership and Community Connections, Dean of Students Office at (309) 438-7346. TTY: (309) 438-2762.
Please allow sufficient time to arrange the accommodations.