Fillable 2019-bbcb-conference-application Employment application

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2019-bbcb-conference-application Employment application

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1
2019 BBCB Conference Application – Tampa, Florida, March 7 – 9, 2019
Eligibility
This leadership conference targets Black and Latino male students. ATPA students who
satisfactorily met program requirements and expectations; received grades of A, B, or C in
their spring and summer 2018 semester course load; and grades of A, B, or C in their fall
2018 course load, ,are eligible to apply for ATPA Sponsorship at the 2019 BBCB Conference.
The co
s
t
All
lodging, air
t
r
av
e
l, conference registration fees and conference meals are covered for
this trip by the Achieving the Promise Academy. Each student will receive a
$100
stipend
for independent meals and local travel expenses (e.g. ride share, taxi, meals not
covered by the conference, etc.)
. Meal and local travel expenses in excess of the
$100 stipend will be the responsibility of the participant. Receipts for all meal
and local travel expenses must be submitted to ATPA at the conclusion of the
trip. Any stipend funds not used, or used but not documented by a receipt, are to
be returned to Montgomery College.
Important Dates and Deadlines
Please
r
e
v
i
e
w
and
complete the application
m
a
t
e
r
i
a
l
s
c
a
r
e
f
u
ll
y and
thoroughly.
The application
i
s
du
e
on or
b
e
f
o
r
e Monday, November 26
by
11:59
p.m
.
Mon.,
Dec. 3 A
pp
li
c
a
ti
o
n
s
D
u
e
Wed.,
Nov, 28
Notification
of A
cce
p
t
a
n
ce
Wed., Dec. 19
M
ee
ti
n
g
with ATPA staff
Fri., Jan. 25 Notification of Absence letters to faculty by this date
Wed., Mar. 6
Depart
for
Tampa
Sat., Mar. 9
Return from Tampa
Fri., Mar. 1
5
Receipts submitted to ATPA staff
Expected
B
e
h
av
i
o
r
s
MC
Student Code
of
Conduct
–
P
a
r
ti
c
i
p
a
n
t
s
a
r
e
r
e
p
r
e
s
e
n
t
a
ti
v
e
s
of MC and at
all
times
m
u
s
t f
o
ll
o
w
the
r
e
g
u
l
a
ti
o
n
s
s
ti
pu
l
a
t
e
d
in
the Student Code
of
C
o
ndu
c
t
. Bullying is not tolerated.
S
a
f
e
t
y
2
P
a
r
ti
c
i
p
a
n
t
s
m
u
s
t
a
dh
e
r
e
s
t
r
i
c
tl
y
to
those policies
s
ti
pu
l
a
t
e
d
by the federa l
aviat io n adm in istra tio n, our
site
h
o
s
t
s,
and ATPA f
a
c
ilit
a
t
o
r
s
t
h
r
o
u
g
h
o
u
t
the
t
r
i
p
.
Alcohol
and
Other
Drug F
r
ee
All
p
a
r
ti
c
i
p
a
n
t
s
a
g
r
ee
to
r
e
m
a
i
n
f
r
ee
of
alcohol (if under 21)
and
illegal
s
ub
s
t
a
n
ce
s
for
the
du
r
a
ti
o
n
of
the
t
r
i
p
.
(
P
r
e
s
c
r
i
p
ti
o
n
medicine
i
s
fine,
if
taken as
i
n
s
t
r
u
c
t
e
d
by your
d
o
c
t
o
r
)
.
Anyone
who
uses
o
r
possesses
any of
these prohibited
s
ub
s
t
a
n
ce
s
during
the
trip will
be
r
e
qu
i
r
e
d
to
leave the site
i
mm
e
d
i
a
t
e
l
y,
pay for
their
own t
r
a
n
s
p
o
r
t
a
ti
o
n
home,
and will not
be allowed
to
p
a
r
ti
c
i
p
a
t
e
in f
u
t
u
r
e
ATPA
excursions
.
All t
r
a
n
s
p
o
r
t
a
ti
o
n
expenses
from
the
site
will
be the
r
e
s
p
o
n
s
i
b
ilit
y
of
the offending
p
a
r
ti
c
i
p
a
n
t
a
nd
no f
ee
s
will
be
r
e
i
m
bu
r
s
e
d
.
The
use
or
p
o
ss
e
ss
i
o
n
of any
d
r
u
g
s
for
illegal
pu
r
p
o
s
e
s
i
s
a
v
i
o
l
a
ti
o
n
of
the
M
o
n
t
go
m
e
r
y
College Student Code
of
Conduct. Violations
will
be
r
e
f
e
rr
e
d
to
the
D
e
a
n
of
Student
E
n
g
a
g
e
m
e
n
t
.
S
upp
o
r
ti
v
e
S
p
a
ce
ATPA i
s
intended
to
be
a
s
upp
o
r
ti
v
e
and
safe space.
P
a
r
ti
c
i
p
a
n
t
s
a
r
e
expected
to
be open
a
nd
s
upp
o
r
ti
v
e
of
d
iff
e
r
e
n
t
c
u
lt
u
r
e
s
,
b
a
c
k
g
r
o
und
s
,
r
a
ce
s
,
g
e
nd
e
r
i
d
e
n
titi
e
s
,
sexual
o
r
i
e
n
t
a
ti
o
n
s
,
a
nd
a
b
iliti
e
s
.
Meetings
Pre-trip Meeting:
Attendance
at a
pre-trip
meeting
i
s
m
a
nd
a
t
o
r
y.
P
a
r
ti
c
i
p
a
n
t
s
may—for
e
m
e
r
g
e
n
c
y
r
e
a
s
o
n
s
o
n
l
y
—
m
i
ss
only
one
of
these meetings.
To
make
up for that
a
b
s
e
n
ce
,
p
a
r
ti
c
i
p
a
n
t
s
will
need
to
r
e
v
i
e
w
m
a
t
e
r
i
a
l
s
with an
ATPA f
a
c
ilit
a
t
o
r
.
P
r
e
-t
r
i
p
meetings
will
take place
on a
campus
to
be
announced.
If
accepted,
you will
b
e
asked
to
p
r
o
v
i
d
e
your
availability
for
the
Wednesday, December 19
meeting so
it
can be scheduled as soon as
p
o
ss
i
b
l
e
.
Debrief Meeting:
A debrief meeting will be held on the last day of the
conference. All participants are required to attend. In preparation,
participants will write a reflection about their conference experience and
share with the group during the meeting.
Applicant Information
Full Name:
Last
First
M.I.
3
Address:
Street Address
Apartment/Unit
#
City
State
ZIP Code
Phone:
MC Email
M #:
M
GPA
No. Earned
Credits:
Gender
identity:
Male
Female
Other
If other, please
specify:
Date of Birth:
/ /
Will you be at 21+ at time of travel?
YES
NO
Race and
Ethnicity:
Are you a first-generation college student?
YES
NO
Campus:
Do you have a state issued ID?
YES
NO
If no, do you have a passport?
YES
NO
Have you previously attended a
conference?
YES
NO
If yes, which
conference(s)?
Major:
Expected Graduation or transfer
date:
/ /
4
Character References (Academic Coach and a supervisor, Instructor, or Advisor)
Two character references required (one reference must be your ATPA Academic Coach).
Please inform your references ahead of time and let them know to expect to receive a
notification from ATPA.
Full Name:
Relationship
Academic Coach
Email:
Phone:
Full Name:
Relationship
Email:
Phone:
Essay Questions (Each answer should be between 100 and 150 words)
You must answer all questions. Responses with fewer than 100 words will not be
considered. Responses will be evaluated based on relevance to the question, thoroughness,
and mechanics (e.g. grammar, punctuation, etc.)
1) Why do you want to participate in this conference? Consider your personal values,
interests, and goals as a student. (100-150 words)
2) Please describe a challenge you have had to overcome on your academic journey.
(100-150 words)
5
3) What do you think you would be able to contribute as a participant in this conference?
(100-150 words)
Participant Responsibility Agreement
S
e
l
ec
ti
o
n
:
I
und
e
r
s
t
a
nd
that all
completed
a
pp
li
c
a
ti
o
n
s
will
be
r
e
v
i
e
w
e
d
for
acceptance
and that
s
e
l
ec
ti
o
n
s
w
ill
be based upon
r
e
f
e
r
e
n
ce
s
,
essay
r
e
s
p
o
n
s
e
s
,
and
c
o
n
s
i
d
e
r
a
ti
o
n
of what i
s
best
for
the
p
r
og
r
a
m
a
nd
g
r
o
up
.
Pre–trip
M
ee
ti
n
g
s
:
As
conference
p
a
r
ti
c
i
p
a
n
t
,
I
a
g
r
ee
to
p
a
r
ti
c
i
p
a
t
e
in all
pre-trip
a
c
ti
v
iti
e
s
.
I
und
e
r
s
t
a
nd
that if
I
do
n
o
t
p
a
r
ti
c
i
p
a
t
e
,
I
may
be removed from the trip
.
Conference
P
a
r
ti
c
i
p
a
n
t
P
o
li
c
i
e
s
:
6
I
a
g
r
ee
to
r
e
m
a
i
n
f
r
ee
of
alcohol
and
illegal
s
ub
s
t
a
n
ce
s
for
the
du
r
a
ti
o
n
of
the
trip and
und
e
r
s
t
a
nd
that
anyone
who
uses
or
possesses
any of
these
s
ub
s
t
a
n
ce
s
during
the
trip will
be
r
e
qu
i
r
e
d
t
o
l
e
av
e
the site
immediately
and
will not
be allowed
to
p
a
r
ti
c
i
p
a
t
e
in f
u
t
u
r
e
ATPA excursions
.
o
I
und
e
r
s
t
a
nd
that in t
h
i
s
case
all t
r
a
n
s
p
o
r
t
a
ti
o
n
expenses
from
the site
will
be
my
r
e
s
p
o
n
s
i
b
ilit
y
a
nd
no f
ee
s
will
be
r
e
i
m
bu
r
s
e
d
.
I
also
und
e
r
s
t
a
nd
that
the incident
will
be
r
e
f
e
rr
e
d
to
the Dean
o
f
Student
S
e
r
v
i
ce
s
.
I
a
g
r
ee
to
abide
by
the
MC
Student Code
of
Conduct
at all ti
m
e
s
.
I agree that bullying will not be tolerated and could lead to immediate dismissal from the trip.
I
a
g
r
ee
to
p
a
r
ti
c
i
p
a
t
e
fully in
the conference
as
a
rr
a
n
g
e
d
by
the host
agency
and to
be sensitive
of
a
nd
open
to
c
u
lt
u
r
a
l
d
iff
e
r
e
n
ce
s
.
I
a
g
r
ee
to
follow
all
safety
p
r
o
ce
du
r
e
s
established
by ATPA f
a
c
ilit
a
t
o
r
s
and
site
f
a
c
ilit
a
t
o
r
s
.
I
und
e
r
s
t
a
nd
that
I
will
meet the
ATPA
g
r
o
up
at MC and t
r
av
e
l to and from
the
conference
site as
a
g
r
o
up
.
I
und
e
r
s
t
a
nd
that any
p
e
r
s
o
n
a
l t
r
i
p
s
while
on
the
conference trip will not
be
p
e
r
m
itt
e
d
and that
I
w
ill
p
a
r
ti
c
i
p
a
t
e
fully in all
planned
g
r
o
up
a
c
ti
v
iti
e
s
.
I
will
complete
and
s
ub
m
it all
r
e
qu
i
r
e
d
f
o
r
m
s
and fulfill my
financial
o
b
li
g
a
ti
o
n
s
.
I
am 18
y
e
a
r
s
of
age
or
o
l
d
e
r
or
have signed
p
e
r
m
i
ss
i
o
n
from my
p
a
r
e
n
t or
g
u
a
r
d
i
a
n
to
p
a
r
ti
c
i
p
a
t
e
.
I
am
e
n
r
o
ll
e
d
in at
least one
f
o
r
-
c
r
e
d
it
c
o
u
r
s
e
during
the spring 2019
s
e
m
e
s
t
e
r
at
MC.
Payment P
o
li
c
y
:
I
und
e
r
s
t
a
nd
that
I will receive as
$100 stipend and
a
g
r
ee
to submit all receipts by
Friday, March 12 for eligible expenses and return any unused stipend monies.
I
und
e
r
s
t
a
nd
that
I
will f
o
r
f
e
it any and all
p
ay
m
e
n
t
s
that
I
have made
if
I
m
u
s
t
withdraw from
the
conference
trip
after
December 19
.
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
By signing my name below, I indicate that I have read and fully understand the policies as
stated above and agree to the terms of this contract. I understand that failure to abide by these
policies can result in expulsion from the trip and exclusion from all future ATPA excursions.
Signature:
Date:
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2019-bbcb-conference-application Employment application

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Completed 22 February 2020

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