here - The University of Texas at Dallas

ASB Site Leader Application
Due: Friday, October 31st by 5:00 p.m.
Submit completed application, copy of valid drivers license, and a copy
of medical insurance card to the Office of Student Volunteerism at
SSB 3.600, email to [email protected],
or fax to (972) 883 - 6183
Applicant's Name:_______________________________________
Packet Contents
l.
Cover Page ...................................................................................................................................................................... Page 1
II.
Overview of Site Leader Responsibilities.............................................................................................................. Page 2
lIl. Overview of Site Leader Responsibilities - Continual ..................................................................................... Page 3
IV. Applicant Data .............................................................................................................................................................. Page 4
V.
Trips Preference to Site Lead.......................................................................................................................................Page 5
VI. Site Leader Questions................................................................................................................................................. Page 6
Van trip registration will be available online on Wednesday, December 3rd at Noon
www.utdallas.edu/springbreak
For Official Use Only:
Upon submission of application check for completion of each page and initial corresponding boxes.
Page 1 _____
Page 5 _____
Copy of Valid Driver's License or Photo I.D.
_____
Page 2 _____
Page 6 _____
Copy of Valid Medical Insurance Card
_____
Copy of Valid Car Insurance
_____
Page 3 _____
Page 4 _____
Required of potential drivers, See Page 4.
Page 1 of 6
Overview of Site Leader Responsibilities
Initial
This is only an overview. Additional responsibilities and obligations will be discussed in training.
Friday, October 31st - Site Leaders / Asst. Site Leaders Applications Due
Friday, November 14th - Site Leaders / Asst. Site Leaders notified of trip placements
Wednesday, December 3rd at Noon - Van Trip Online Registration Begins (team members)
ASB Training Dates: Initial by each of the following dates to confirm that you understand you are
required to attend all of the meeting times.
Wednesday, January 14th, 2:00 pm - 3:00 pm: Leadership meeting (Site Leaders / Asst. Site Leaders & RUO) - Phoenix Room (SU 2.508)
Wednesday, January 28th, 2:00 pm - 3:00 pm: Leadership meeting (Site Leaders / Asst. Site Leaders & RUO) - Phoenix Room (SU 2.508)
Wednesday, February 11th 2:00 pm - 3:00 pm: Leadership meeting (Site Leaders / Asst. Site Leaders & RUO) - Libra Room (SU 1.614)
Friday, February 13th 4:00 pm - 5:30 pm: Mandatory Leadership Retreat - Residence Hall
Tuesday, February 24th 10:00 am - 11:00 am: ASB Orientation for all participants (Option A) - Galaxy
Wednesday, February 25th 2:00 pm - 3:00 pm: Leadership meeting (Site Leaders / Asst. Site Leaders & RUO) - Libra Room (SU 1.614)
Friday, February 27th 2:00 pm - 3:00 pm: ASB Orientation for all participants (Option B) - Galaxy
Wednesday, March 11th 2:00 pm - 3:00 pm: Leadership meeting (Site Leaders / Asst. Site Leaders & RUO) - Phoenix Room (SU 2.508)
Sunday-Saturday, March 15th-21st ASB travel dates (may vary per trip)
Wednesday, March 25th 2:00 pm - 3:00 pm: Leadership meeting (Site Leaders / Asst. Site Leaders & RUO) - Libra Room (SU 1.614)
Friday, April 17th 6:00 pm - 7:30 pm - ASB Reflection Reception - Faculty Staff Dining Hall
List known conflicts (include date and reason):
Trip Dates: I am available throughout the week of Spring Break, March 15th-21st, 2015. Trips may be scheduled at any time during these days.
ASB participants must travel and stay with group for the duration of the trip.
Team Meetings: I understand that it is my responsibility as a Site Leader to schedule, prepare, and host team meetings
through mid-April 2015. The specific times will be determined per team according to the majority of team members
schedules.
As a Site Leader I am also expected to help coordinate and support my team's activities, including, but not limited to, service
projects, team building and other ASB events.
Financial Obligations: I understand my spot is not confirmed and I will not be able to go on the trip until my
Alternative Spring Break Fee is paid in full by the deadline.
Cancellation Policy: I understand that all payments are non-refundable. If I am on an air travel trip and I cancel my participation I understand that my airplane tickets are non-refundable and non-transferable. Should I cancel my participation, I
am responsible for making necessary adjustments and paying cancellation fees.
Page 2 of 6
Overview of Site Leader Responsibilities - Continued
Medical Insurance: I must have medical insurance in order to participate in Alternative Spring Break. I am required to
provide current proof of medical insurance at least one month prior to departure. Student health insurance is available at
utd.edu/insurance or may be available through the Office of Student Volunteerism.
Weapons, Drugs, and Alcohol: Use and/or possession of weapons, alcohol or illegal drugs is forbidden while traveling on a
University-sponsored trip. The Alternative Spring Break program prohibits the purchase and consumption of alcohol and
illegal drugs by all participants, regardless of age, during all ASB events, including travel to and from sites. I understand that
if I do not follow this policy I will be asked to withdraw my participation, am responsible for any costs incurred and will
have to return to my place of residence at my own expense.
Scholarship Release: Pursuant to The Family Educational Rights and Privacy Act of 1974, I hereby consent to the release of
my grade point average [cumulative and prior terms(s)] and grade reports for prior terms to the Assistant Director of the
Office of Student Volunteerism.
This information may be used by the office for use in awards recognition and for verification of achievement of minimum
academic standards. I understand that I must be a registered student at UT Dallas in good academic standing in order to
serve as a Site Leader. This authorization shall remain in effect as long as I am enrolled at this institution, unless I revoke this
authorization in writing.
I have read and I agree to adhere to the Overview of Site Leader Responsibilities.
Signature:
Date:
Page 3 of 6
Alternative Spring Break 2015
UT Dallas Office of Student Volunteerism
800 W. Campbell Rd., SSB 33
Richardson, TX 75080
972-883-6131
www.utdallas.edu/springbreak
Site Leader Application
Complete this application and return to the Office of Student Volunteerism, SSB 3.600, by 5:00 p.m. Friday October 31st, 2014.
Incomplete applications will not be considered. ASB Fee is not due when application is submitted. ASB Fee wil be determined
upon confirmation of Site Leader placement and will be due Friday, November 21st, 2014 by 5:00 p.m.
Applicant Data
Name
Student ID
E-mail Address
Cell Number
Classification
Home Number
Major
T-Shirt Size
Address 1
City
Address 2
State
Zip
General Information
If not selected to be a Site Leader, are you interested in becoming an Assistant Site Leader?
Yes
No
Site Leaders and Asst. Site leaders are expected to drive during the trip.
Do you have a United States-issued driver's license?
Drivers License #
Yes
You must provide copies of your driver's license and
valid car insurance with application.
State Issued
Are you CPR certified through March 2015?
If not, would you be willing to become certified?
No
Yes
No
Yes
No
List any allergies or dietary needs:
List any accommodations that you need, i.e. sign language interpreter, wheelchair access, etc.
Please attach a copy of your drivers license, car insurance and medical insurance card to this application.
11/10
Page 4 of 6
Trip Preference to Site Lead
*All trip destinations and trip cost are subject to change.
Location assignment will be discussed and confirmed once approved for Site Leader position.
Full payment due at registration for all trips. For Site Leaders, ASB fee will be determined upon your confirmation of Site Leader placement
and will be due by Friday, November 21st, 2014.
Air Travel Trips
Social Issue: Sustainability
Agency: Petaluma Bounty
ASB Fee: $450.00
Petaluma, CA
Social Issue: Hunger and Homelessness
Agency: Atlanta Center for Self Sufficiency
ASB Fee: $350.00
Social Issue: Education
Agency: Junior Achievement of New
York (JANY)
ASB Fee: $450.00
New York, NY
Atlanta, GA
Van Trips
Social Issue: Affordable Housing
Agency: Habitat for Humanity
ASB Fee: $100.00
Social Issue: Park Preservation
Agency: Oklahoma State Parks
ASB Fee: $75.00
Jackson, MS
Hulbert, OK
Social Issue: Environmental Conservation
Agency: Galveston Bay Foundation
Galveston, TX
ASB Fee: $100.00
Social Issue: Animal Services
Agency: Turpentine Creek Wildlife
ASB Fee: $100.00
Social Issue: Social Services
Agency: San Antonio Food Bank
ASB Fee: $100.00
San Antonio, TX
Social Issue: Immigration and Refugee Services
McAllen, TX
Agency: Proyecto Azteca
ASB Fee: $100.00
Social Issue: Disaster Relief
Agency: Rebuilding Together OKC
ASB Fee: $100.00
Moore, OK
Eureka Springs , AR
#1 Preferred Social Issue
#2 Preferred Social Issue
#3 Preferred Social Issue
#4 Preferred Social Issue
Page 5 of 6
Site Leader Questions
Please answer each of the following questions. You may attach a separate sheet with your responses.
1) Briefly describe the most memorable experience of your previous ASB trip or favorite volunteer experience and why it
has led you to want to become a Site Leader for ASB.
2) Respond to the following scenario: Due to transportation issues (flight delayed, van issues, etc.) your group can't get home for
another day. Many of your members are concerned about academics and work in the upcoming week and tensions are high.
How do you keep moral up and ease tensions?
3) Please share any other information or comments you would like to add pertaining to your potential role as a Site Leader
and/or your participation in the Alternative Spring Break program.
The University of Texas at Dallas is an affirmative action/equal opportunity university.
Students with disabilities needing assistance contact 972-883-6393. TX Relay: 1-800-RELAYTX
Page 6 of 6