East Coast Student Leadership

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East Coast Student Leadership

November 6 – 8, 2015

The East Coast Student Leadership Conference is an opportunity for student leaders from the Atlantic region, and beyond, to come together and share ideas, become inspired, and leave determined to make a difference on their on campus and/or in their community.The conference is comprised of workshops, networking and brainstorming sessions, social activities, and keynote presentations, all designed to help you learn, grow, and prepare to take action!

Return this completed application by no later than 4:30pm on October 22, 2015 to Student Services and Residence Life – George Martin Hall 311 or via e-mail to .

STUDENT INFORMATION
Name: / Student ID:
Phone: / Alt. phone: / E-mail address:
Major (if declared): / Year of Study:
Local Street address:
City: / Province: / Postal code:
EXPECTATION AGREEMENT (Please initial in appropriate box to confirm your agreement)
I understand the registration fee for this conference is $50.00 and due within one week of being selected to participate.
East Coast Student Leadership Conference is a dry program. I understand that consumption of alcohol and the use of drugs is prohibited throughout my participation in this trip (this includes activities leading up to and after the trip).
East Coast Student Leadership Conference requires the full commitment of participants. I agree to participate actively in all aspects of the program including attending a pre-trip meeting tentatively planned for Monday, November 2ndat 9:00am. More information, including the location will be communicated to successful applicants.
Please answer the following questions to the best of your abilities.

Why do you want to participate in the 2015 East Coast Student Leadership conference?

What does student leadership mean to you?

Describe any experiences you have had with student leadership.

Student Participant Information
Full Name: / Student ID:
Information you wish to disclose regarding medical condition(s), medications, allergies etc:
Emergency Contact #1 (should have knowledge of any medical condition(s), medications, allergies, etc…)
Full Name: / Relationship:
Phone Number: / Alternate Phone Number:
Address:
Emergency Contact #2 (should have knowledge of any medical condition(s), medications, allergies etc… )
Full Name: / Relationship:
Phone Number: / Alternate Phone Number:
Address:
I consent to the disclosure of the information in this document as necessary in the event of an emergency. I acknowledge that I have informed my Emergency Contact(s) of this designation.
Signature: / Date:

St. Thomas University collects and protects personal information under the authority of the New Brunswick Freedom of Information and Protection of Privacy Act for the purposes of operating the programs and services of the University. The personal information collected on this form will be used only in the event of an emergency in order to contact an individual traveler’s designated emergency contact.

The information in this form may be accessed by the Student Services and Residence Life Office for the purpose of facilitating the East Coast Student Leadership Conference. The original of this form will be kept in a secure file in Student Services, GMH 311.