|
ICAS to The ICAS Youth Excellence Program Institute for Corean-American Studies, Inc. www.icasinc.org Leadership Training Conference in Washington D C August 13, 2009 Thursday 6:00 AM - 10:30 PM Let's Learn More about America Opening Young Minds and Expanding Horizons Building Capacity, Fostering Opportunity, Investing in the Future Enhancing Good and Productive Citizenship Meet, Visit, Greet, Brief Mount Vernon Pentagon The White House (subject to amend, change, modification and security clearance/environment) parents youth (college students, gradaute/post-graduate students) adult Guide and Faculty: ICAS Staff Inquiry: ICAS@icasinc.org REGISTRATION First Come First Served; A Security Clearance Process (SCP) will commence immediately upon commitment to participate. RSVP by August 10, 2009 Student's/Participant's Name: ________________________________grade___________________ Email __________________________________ Tel __________________________________ Date of Birth ____________________________________________________________________ Place of Birth ___________________________________________________________________ Nationality __________________ Passport Number (for non-US citizen) _____________________ Social Security Number (for security clearance purpose only)________________________________ Father's/Mother's/Guardian's Name ___________________________________________________ Mailing address __________________________________________________________________ Tel ______________________ Fax ________________ Email _____________________________ Name of school __________________________________________________________________ Principal's name __________________________________________________________________ Tel: _____________________ Fax: ________________ Email _____________________________ Participating students will be invited to an orientation workshop+ which will include a lecture on How to Build Brain Power? How to Enhance Academic Performance? Preparing for College/University (i.e., BA, BS) Graduate School/Professional School (i.e., PhD, JD, MBA, MD) Preparing for Post-College/University Career Development ** ICAS Youth Fellowship AwardRelease of Liability Date this form executed _______________________________ Applicant's Name ________________________________ DOB _________________________ Age __________________ Grade ___________________ Signature ______________________ Parent/s, Guardian/s Name/ _________________________________________________________ Mailing Address _________________________________________________________________ Name of School you attend _________________________________________________________ Principal's Name _____________________________ Tel ________________________ Fax _________________ Email ______________________ Emergency Contact Person __________________________________________________________ Relationship _________________ Tel __________________ Email _________________________ Any Concerns (i.e., medical, et al) of which we should be aware. (Please use a separate page if needed) _______________________________________________________________________________ Health Insurance Inforamtion: Policy Name _____________________________________________ Policy Holder _____________________________________________ Policy Number ____________________________________________ How did you hear about the ICAS Youth Excellence Program ( ICAS YEP)? _______________________________________________________________________________ Did you participate in the ICAS YEP during the past year? _______________________________________________________________________________ In consideration of acceptance as a participant in the ICAS YEP, I hereby agree for myself, my heirs, my executors, administrators and any minor child (if applicable) to waive and release any and all rights and claims for damages I may have against the ICAS , its employees, other ICAS members, directors, staff, fellows, and their respective families, sponsors, and their representatives, successors, and assigns and will hold them harmless for any and all inuries suffered in connection with any ICAS YEP event/s or while traveling to or returning there from. Also, non of the above are responsible for the loss of personal items and any other form of aggression in connection with any ICAS YEP activities. I verify that I am physically fit and that my physical condition has been verified by a licensed medical doctor. I also hereby consent to permit emergency treatment in the event of injury or illness. Signature of parent(s)/guardin _______________________________ Date _______________________________ NB: A parent/guardian must fill in this form. ICAS reserves all rights including the right to dismiss any participant and, in that case, no refunds shall be made. Any cancellation requiring a refund must be made in writing with two weeks advance notice. Otherwise, there shall be no refunds. Further details will be provided upon completion of registration. --------------------------------------------------------------------------------------------------------- veritas vos liberabit Sang Joo Kim Sr Fellow & Executive Vice President Institute for Corean-American Studies, Inc. ( ICAS) ICAS Liberty Foundation 965 Clover Court Blue Bell, PA 19422 E: icas@ ICAS inc.org -------------------------------------------------------------------------------------------------------- Institute for Corean-American Studies (aka ICAS) is a non-profit, non-partisan, and private educational and research organization. It is not an agent of any government and solely supported by voluntary contributions. ICAS promotes pertinent relations and conducts appropriate activities to enhance cooperation and to pursue peace and prosperity. Further information about ICAS and some examples of the recent activities may be found on the ICAS website (http://www. ICASinc.org). Thank you. -------------------------------------------------------------------------------------------------------- ICAS Liberty Foundation seeks to promote the cause of humanity, peace, prosperity and security through cultural, educational and research activities. All Rights Reserved. August 7, 2009 |