Dear Freshman Javelina Applicant

Dear Freshman Javelina Applicant:

Thank you for your interest in Texas A&M University-Kingsville’s Bridges to Success Program. The Bridges to Success Math and Science Campis a three (3) week summer program designed for incoming Javelina freshmen (majoring in Engineering, Agriculture or Pre-Health Sciences)that are interested in taking the necessary steps to jumpstart their academic career. Math Camp students will refresh their math skills and progress through the ALEKS program, an online tool, that helps quantify a student’s preparation for Trigonometry and Calculus I. Students will also increase their science literacy through hands-on labs. Camp participants will have the opportunity to:

Experience residence life on our university campus
Take part in academic and social enhancement workshops
Network with faculty, staff, and administrators

Cost Per Student
Housing / $300.00
Meal Plan / $370.00
ALEKS / $50.00
Camp Fees / $600.00
Total / $1,320.00

If you are interested in participating in the Bridges to Success Program, please complete the enclosed application packet and return all documents to your college’s point of contact by Wednesday, July 5, 2017.

Complete Bridges to Success Program application
Unofficial copy of high school transcript and testing scores

Return all items to your Academic Advisor or designated College point of contact.

We will review applications as they are received in order to provide applicants with prompt notification of admission status. We can only accommodate 40 students for the Bridges to Success program (15 Engineering, 15 Agriculture, 10 Pre-Health Science students); therefore, interested applicants are urged to apply early.

Bridges to Success Math Camp will begin July 10thand will end on July 28th, with check in on Sunday July 9th.

If you have any questions and/or concerns, please feel free to contact your college’s point of contact.

Engineering
Austin McCoy
Director, Javelina Engineering Student Success Center
700 University Blvd., MSC 155
Kingsville, Texas 78363
(361) 593-2799
Fax (361) 593-4466

Agriculture
Javier Mendoza
Professional Academic Advisor
700 University Blvd., 156
Kingsville, Texas 78363
(361) 593-3718
Fax (361) 593-3713

Pre-Medical Science
J. Eric Winterbottom
Pre-Health Sciences Coordinator
700 University Blvd., 117
Kingsville, Texas 78363
(361) 593-3797
Fax (361) 593-2379

Payments:

Once the application has been processed and you have been accepted in the Bridges to Success Math and Science Camp,

payment can be completed through MoneyConnect at:

Refund Policy

No refunds after the Bridges to Success program begins.
We reserve the right to cancel the Bridges to Success program with fewer than12 students. Full refunds will be given if we cancel the program.

Participant Application

Name______Date______

Last FirstMiddle

MailingAddress______

Street CityStateZip code

Home Phone ( ) ______Email Address______

Cell Phone ( ) ______K#______

Ethnic / Racial Background____African American ____Caucasian ____Hispanic____Asian or Pacific Islander ____American Indian ____Other___ please specify

Gender:Male or FemaleDate of Birth ______Current Age: ______

High School Information:

Name______Graduation Date______HS GPA____

List your extra-curricular activities below:

______

Parent(s)/Guardian Information:

Parent(s)/Guardian______

LastFirst

MailingAddress______

StreetCity StateZip Code

Home Phone ( )______Email Address______

Cell Phone ( )______Email Address ______

Parent(s) or guardian graduated from a four-year institution?Yes___ No___

Have you applied to Texas A&M University-Kingsville for Fall 2017 admission? Yes or No

Which camp will you be attending:

College of Engineering Math ______

College of Agriculture Math Camp _____

Pre-Health Science Camp _____

I will or will not be going home on the weekends (please circle)

T-Shirt Size ______

Texas A&M University-Kingsville Bridges to Success Program

Emergency Information

Name: ______Date of Birth: ______Gender: ___

Parent/Guardian Name(s): ______

Parent/Guardian Name:______

Address: ______

City: ______ST: ______Zip: ______

Day Time Phone: ______Evening Phone: ______

Cell Phone: ______

Parent/Guardian’s Email address: ______

If we CAN NOT REACH YOU, list in order of whom to call in case of an EMERGENCY?

Name: ______Phone: ______

Relation: ______

Name: ______Phone: ______

Relation: ______

PEOPLE ALLOWED TO PICK-UP YOUR STUDENT

Name: ______Phone: ______Relationship:______

*If someone else is picking-up your student who isn’t on this form, write a note & give to camp staff with their name, phone number & relationship to student.

Texas A&M University-Kingsville Bridges to Success Program

HEALTH & MEDICAL INFORMATION

(Please check ALL that apply)

___ Asthma/Respiratory Condition ___ Attention Deficit Disorder

___ Heart Condition ___ Diabetes

___ Epilepsy ___ Sun Burns Easily

___Other(specify)______

Seizures, Type & Frequency ______

Bee Sting Allergy: ______Reaction:______

Pollen or Food Allergies: ______Reaction: ______Medication Allergies: ______Reaction: ______

Does the Participant have a disability requiring any accommodations? Yes / No

If yes, please explain: ______

Is your student is taking medication? Yes / No

If yes, please complete a Medication Dispensing Information form.

Are there any other health or medical concerns we should know about?Yes / No

If yes, please explain: ______

/ PARTICIPANT WAIVER, INDEMNIFICATION, AND MEDICAL TREATMENT AUTHORIZATION FORM / CAF 7

1. EXCULPATORY CLAUSE. In consideration for receiving permission to participate in any and all activities of Bridges to Success programs (herein referred to as “activity”), which is sponsored by Center for Student Success at Texas A&M University-Kingsville (herein referred to as “sponsor”), a member of The Texas A&M University System, I hereby release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes sponsor, The Texas A&M University System, the Board of Regents for The Texas A&M University System, and their members, officers, servants, agents, volunteers, or employees (herein referred to as RELEASEES or INDEMNITEES) from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, that may be sustained by me while participating in such activity, while traveling to and from the activity, or while on the premises owned or leased by RELEASEES, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct.

2. INDEMNITY CLAUSE. I am fully aware that there are inherent risks to myself and others involved with this activity, including but not limited to bodily harm, and I choose to voluntarily participate in said activity with full knowledge that the activity may be hazardous to me and my property, and to the person and property of others. I acknowledge there may be physically strenuous activities. I know of no medical reason why I should not participate. I agree to indemnify and hold harmless INDEMNITEES from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, which may occur to myself, other participants, and third-persons as a result of my participation in said activity, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of INDEMNITEES.

3. NO INSURANCE. I understand that RELEASEES do not maintain any insurance policy covering any circumstance arising from my participation in this activity or any event related to that participation. As such, I am aware that I should review my personal insurance coverage. Sponsor does not carry general liability insurance to cover claims arising from this activity so it seeks a waiver of claims as additional consideration for the right to participate so sponsor, a governmental unit of the State of Texas, can (a) provide the activity at the lowest possible cost to participants; and (b) provide access to a greater number of participants by expending limited resources on program materials rather than on liability insurance.

4. BINDS HEIRS. It is my express intent that this agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of Texas.

5. MEDICAL AUTHORIZATION, INDEMNITY FOR MEDICAL EXPENSES, and WAIVER. I understand RELEASEES cannot be expected to control all of the risks articulated in this form and RELEASEES may need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment that may be required, as determined by a medical professional at the medical facility, during my participation in this activity with the understanding that the cost of any such treatment will be my responsibility. I agree to indemnify and hold harmless INDEMNITEES for any costs incurred to treat me, even if an INDEMNITEE has signed hospital documentation promising to pay for the treatment due to my inability to sign the documentation. I further agree to release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes, RELEASEES from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, that may be sustained by me while receiving medical care or in deciding to seek medical care, including while traveling to and from a medical care facility, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct.

6. VOLUNTARY SIGNATURE. In signing this agreement I acknowledge and represent that I have read it, understand it, and sign it voluntarily as my own free act and deed; sponsor has not made and I have not relied on any oral representations, statements, or inducements apart from the terms contained in this agreement. I execute this document for full, adequate and complete consideration fully intending to be bound by the same, now and in the future. I understand I can choose not to sign this document and free myself from its terms and the associated risks of the activity by simply not participating in the activity and choosing some other activity available to me that has a lower level of risk to me. I further understand this is a voluntary, extracurricular activity; therefore it is not required for me to obtain college credits and not participating in this activity will in no way hinder my ability to obtain a degree from the university. [For fieldtrips or other class-related activities, substitute: I understand participation in this class/fieldtrip/activity is not mandatory and I will not be penalized for failing to participate in this activity because an alternative activity exists for which I can receive like credit. While I understand alternative activities are available to me that do not have the risks associated with this activity I still desire to voluntarily engage in this activity.]

SIGNING THIS DOCUMENT INVOLVES THE WAIVER OF VALUABLE LEGAL RIGHTS.

CONSULT YOUR ATTORNEY BEFORE SIGNING THIS DOCUMENT.

SIGNED this ______day of ______, 20______.

Participant Signature: ______

Printed Name: ______

Participant’s Date of Birth: ______

Parent or Legal Guardian Signature: ______

(If Participant is under 18 years old)

Parent or Legal Guardian Printed Name: ______

(If Participant is under 18 years old)

EMERGENCY CONTACT INFORMATION:

Name:______Relationship ______

Home Address: ______

Home______Work______Cell ______

Phone # Phone # Phone #

Name:______Relationship ______

Home Address: ______

Home______Work______Cell ______

Phone # Phone # Phone #

This form adapted from TAMU Camp Forms.

Texas A&M University-Kingsville Bridges to Success Program

Code of Conduct

Camper Name: ______

Camp Name: ______

Parents/Guardian:

Please review the following behavior contract with the camper. Ensure that he/she understands that he/she will be expected to follow all parts of the agreement while at camp. Failure to follow these rules will lead to disciplinary actions up to expulsion from camp, without refund.

The camper must read and initial each statement and sign, along with his/her parent or guardian, at the bottom to show that he/she agrees to abide by the rules and policies of the Bridges to Success camp program.

While at camp, I will do the following:

______Make a strong effort to engage in camp programming and constructively work and interact with other campers.

______Respect the needs and feelings of others and show kindness to all with whom I come in contact.

______Show respect for camp staff through my attitude and behavior including following directions.

______Demonstrate a high-level of responsibility and care with University property (including room keys), my

property, and the property of others. I understand that the destruction or defacement of property will result in

disciplinary actions and monetary compensation for the damaged items.

______Wear clothing that is appropriate and shows respect for myself and others. My clothing will be size-appropriate,

modest, and not display inappropriate or disruptive slogans, gestures, or brands.

______Limit my use of electronic devices to non-instructional time only. I am aware that loss, damage, or theft of such

items is not the responsibility or concern of camp staff, Bridges to Success, or Texas A&M University-

Kingsville employees.

______Maintain language and decorum appropriate for the classroom setting at all times.

While at camp, I will NOT do the following:

______Use physical violence, violent language, or threats, which are disruptive or unlawful.

______Bring items which are unlawful or prohibited, including but not limited alcohol, drugs, or firearms.

______Abuse substances, including alcohol or drugs, or engage in inappropriate and/or dangerous use of classroom or

household materials.

______Have guests of the opposite gender in my room. Parents of either gender are allowed in the room when

dropping off or picking up campers, but the door must remain open during this time.

______Engage in behavior which is sexually inappropriate, threatening, or harassing.

______Drive my vehicle, nor will I otherwise leave campus without camp staff knowledge.

______Use profanity.

NOTE, Bridges to Success camps have a zero-tolerance policy concerning physical and verbal violence, illegal and prohibited substances and items, and sexually inappropriate activities.

Having read and understood the Camper Behavior Contract above, I agree to follow these policies during my time in the camp program. I also understand that failure to comply with these policies will have consequences which may include, but are not limited to being prohibited from participating in some or all activities, being dismissed from the camp and sent home, and being prohibited from returning to this and/or future Bridges to Success camp programs.

Camper Signature ______Date ______

Parent/Guardian Signature ______Date ______

Texas A&M University-Kingsville Bridges to Success Program

Transportation To and From Campus

It is the sole responsibility of the participant or parent/guardian to provide transportation to and from the Texas A&M University-Kingsville campus during the weeks of the Bridges to Success program. Texas A&M University – Kingsville is in no way responsible for incidents that may occur during transportation of participants to and from Bridges to Success.

Student Name: ______

Student Signature: ______Date:______

Parent Name: ______

Parent Signature: ______Date:______

Please list the names of people who are authorized to provide transportation for the above named student.

Name: ______Relationship to Student: ______

Phone number: ______

Name: ______Relationship to Student: ______

Phone number: ______

Name: ______Relationship to Student: ______

Phone number: ______

Name: ______Relationship to Student: ______

Phone number: ______

If the student is under age 18, there must be consent by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of ______, named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.

______

(Parent/Guardian’s Printed Name)

______

(Parent/Guardian’s Signature)(Date)

Texas A&M University-Kingsville Bridges to Success Program

Check In and Out Procedures

It is optional for students to return home on weekends.

Limited activities will occur on the weekends.

Check-out is on Fridays 1:00 p.m. to 8:00 p.m.

Check-in is Sunday: Between 12:00 p.m. to 4 p.m.

Times subject to change.

I will or will not be going home on the weekends (please circle)

Parking on the Texas A&M University-Kingsville Campus

Parking on the Texas A&M University – Kingsville campus is strictly prohibited without the purchase of a parking permit. Failure to have a parking permit may result in a fine from the University Police Department.

Parking permits will be provided to the participants of the Bridges to Success program for the designated weeks. These parking permits will be provided at check-in. Please arrive on campus early in order to receive your parking permit prior to the start of the Bridges to Success camp.

____ I will not need a parking permit. ____ I will need a parking permit.

Students will be required to submit their keys to program staff Sunday through Friday. Keys may be issued to students on Fridays at 1 p.m. Vehicle keys must be checked back into program staff on Sunday by 4 p.m. Students checking out their vehicles will need to provide a detail itinerary of their intended travel and adhere to program’s policies regarding leaving campus.

Name of Student ______

Student’s Driver’s License Number: ______

Vehicle Make / Model ______

Student Signature ______

Parent Signature ______

Texas A&M University-Kingsville Bridges to Success Program

Appearance Release Form

I hereby authorize the Texas A&M University-Kingsville (the University), including any of its officers, employees, contractors, and agents, to photograph, videotape, film or record me in any media in relation to my participation in any Summer Bridge Program activities. The University may use my name, image, and likeness, as shown in the photographs, video, film, electronic images, and/or audio recordings in whatever way they desire, including television and web content. I understand that I will not receive any monetary compensation for time or services.

Furthermore, I hereby release and discharge the University from any and all claims and demands arising out of, or in conjunction with, the use of such photographs, video, film, electronic images, and/or audio recordings and the plates, tapes and/or software from which they are made. I understand that these materials shall become the sole property of the University and they shall have the right to duplicate, reproduce and make other uses of the material for any lawful purpose, including illustration, advertising, and promotion. I hereby waive any right of inspection or approval of my appearance or the uses of my appearance in relation to the Bridges to Success Program activities.

______

(Printed Name of Subject)

______

(Signature) (Date)

If the subject is under age 18, there must be consent by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of ______, named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.