beyond hb 1079 conference

BEYOND HB 1079 CONFERENCE Dreaming of a Better Future. Building Communities. Beyond HB 10791 is a student-­‐‑run endeavor made possible through collaborations of both college and high school students, higher education institution support, and dedicated community members who work together towards the common goal of advancing and providing educational opportunities for all students regardless of citizenship. The second Beyond HB 1079 Conference will be held Saturday March 30, 2013 at the University of Washington-­‐‑Bothell campus. The conference is open to college and high school students, parents, and high school counselors. Through a series of workshops, panels, and interactive discussions we hope to meet the following conference goals: 1. Provide HB 1079 Awareness 2. Provide HB 1079 Resources 3. Foster student empowerment The completed Application Form must be turned in no later than March 1, 2013. Please mail forms to: Care of: Beyond HB 1079 Conference
University of Washington
Ethnic Cultural Center
3931 Brooklyn Ave NE,
Seattle, WA 98115
For application pick-­‐‑up request or to receive further information please contact Yuriana Garcia at [email protected]. 1Governor Gary Locke signed House Bill 1079 into law May 7, 2003. The signing of this
bill allows undocumented students to pay in-state tuition at state colleges and
universities beginning July 1, 2003.
Conference Participant General Information Student Name: ________________________________________________________________ Circle one: Female Male Date of Birth: _________________ Grade Level: _________ Phone: (_______) _______________ E-­‐‑mail: ________________________________________ High School: _____________________________Grade Point Average: _________________ Are you eligible to apply to the Deferred Action for Childhood Arrivals program? YES NO I don’t know If yes, have you applied? YES NO Student Agreement Please read through the following list of Student Statement of Expectations and sign below: 1. Participation is mandatory in all activities while you are attending the HB 1079 Conference. 2. Upon arrival, you will receive a folder with necessary information, agenda and materials. Please make sure your folder is with you at all times for reference and note taking. 3. Come prepared to listen to different speakers, ask lots of questions, and spend time with your peers. 4. Participants are expected to be respectful of University staff, property and other attendees. 5. There will be zero tolerance for alcohol or drug use during the Beyond HB 1079 Conference. I have read this statement, agree to the expectations, and will abide by them. I understand that if I do not abide by them, or if I am disruptive or disregard the instructions of the University of Washington staff, I may be asked to leave and my parent/ guardian will be contacted. Student Signature __________________________________Date ____________ 2 Parent/Guardian Consent Form Please provide the following information (print or type). Please also read the Parent/Guardian Statement of Consent and provide your signature below. Por favor, proporcione la siguiente información. Por favor, tambien lea la declaración del padre/guardián de consentimiento con su firma a continuación. General Information Parent/Guardian Name (Nombre del Padre/Guardián): _____________________________________________________________________________ Address (Direcciόόn): __________________________________________________________ _____________________________________________________________________________ Day Phone: (Numero de teléfono por dia) : (______)______________ Evening Phone (Numero de teléfono de noche): (______)_____________ Email (Correro Electrόόnico): _____________________ Emergency Contact If unable to reach parent/guardian, please contact:(si no pueden contactar a los padres o guardian, por favor pόόngase en contacto con): Name (Nombre): ______________________________________________________________ Relationship (Relaciόόn): ________________________________________________________ Day Phone (Numero de teléfono de diá): (____)______________ Evening Phone (Numero de teléfono de noche): (______)____________ 3 Conduct/Liability Section I, ________________________________, as a parent or guardian of the Beyond HB 1079 student conference attendee, __________________________________, recognize that this conference is made possible with the contributions of the University of Washington community and organizations collaboration. As a parent/guardian I understand that my son/daughter’s attendance at this conference is contingent upon his/her appropriate conduct. My son/daughter promises that while at the Beyond HB 1079 Conference, he/she will: 1.
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Act in a respectful and professional manner at all times. Respect individual privacy and comfort. Be aware of and preserve the safety, health and welfare of other individuals. Refrain from conduct that will cause any damage to facilities or equipment during the ride to and from the conference. 5. Refrain from conduct that will cause any damage to facilities or equipment during the conference. 6. Refrain from the consumption or be in the presence of any illegal drugs and/or alcohol. 7. Participate in all activities within the Beyond HB 1079 conference. I agree to assume full responsibility for any risk of injury, death, or property damage arising out of my son/daughter’s participation in the conference and I give permission for them to receive, if necessary, emergency medical services by authorized personnel, and that any cost incurred as a result of such medical emergency will be solely my responsibility. I release the University of Washington’s registered student organization and their affiliates from any liability on account of injury to or death arising out my son/daughter’s participation in Beyond HB 1079 activities and hold the University of Washington and their affiliates harmless of any damage or costs that my incurred due to my son/daughter’s participation in this conference. I have read and understand the above and understand that Conference director reserves the right to expel my son/daughter from the conference if he/she does not live up to this agreement. If for any reason my son/daughter is expelled from the conference, I as a parent will be held responsible for any transportation cost resulting from sending my son/daughter home. Parent/Guardian Signature: ________________________________ Date:_____________ 4 Sección de Conducta y Obligación Yo, _______________________________, como padre o guardian de, ____________________________, que asistira a la conferencia Beyond HB 1079 reconozco que este evento es posible gracias a generosas contribuciones de la Universidad de Washington. Yo entiendo que mi hijo/a permanecera en la conferencia siempre y cuando demuestre una conducta apropiada. Mi hijo/a promete que durante la conferencia él/ella: 1. Actuare con respeto y con modales profesionales a todas horas. 2. Respetara la privacidad individual y comodidad. 3. Estara atento/a y preservara la seguridad, salud y bienestar de otros participantes. 4. Abstendra de conducta que causara perjuicios o daños hacia instalaciones y facilidades durante la transportación. 5. Abstendra de conducta que causara perjuicios o daños hacia instalaciones y facilidades durante la conferencia. 6. Abstendra y mantendra alejado/a del consumo de drogas ilegales y/o alcohol. 7. Participara en todas las actividades patrocinadas por la conferencia. Yo asumiré toda la responsabilidad de cualquier riesgo de peligro, fallecimiento, o destructora de propiedad causada por mi hijo/a durante su participación en la conferencia y no hago responsable a la Universidad de Washington de ningún daño. Sin embargo, doy permiso para que mi hijo/a reciba atención médica en caso de alguna emergencia y yo asumiré todos los gastos médicos. Yo como padre del participante comprendo que la directora de la conferencia tiene el derecho de expulsar a mi hijo/a si viola las reglas escritas en este documento. Si mi hijo/a es expulsado/a de la conferencia, yo asumiré todos los gastos para que mi hijo/a seguramente regrese a su hogar. Firma de padre/guardián: _________________________________ Fecha:______________ 5