- A. Philip Randolph Institute

APRI
A. Philip Randolph Institute
2015 Y.O.U.T.H. Leadership Conference
Aug u s t 1 2 -1 6 , 2 0 1 5
Sa v a n n ah , Ge o rg i a
Dear Student,
The A. Philip Randolph Institute values our youth, recognizing that without the presence of
young minds, our legacy will not continue. Therefore, we would like to invite you to
participate in the 2015 A. Philip Randolph Institute’s Y.O.U.T.H. Leadership Conference.
The conference will convene on August 12-16, 2015 in Savannah, Georgia. More specifically
the conference will be held at the Savannah Marriott Riverfront Hotel, located at 100
General McIntosh Blvd., Savannah, Georgia 31401.
As an APRI youth leader, you will participate in workshops and activities that allow you to
submerge yourself in environments that cultivate powerful civil leaders and social activist.
You will also be able to network with fellow students, activists and labor movement leaders
to further your knowledge of the social, political and economic climate of America.
We welcome you to apply to the 2015 APRI Y.O.U.T.H Conference and anticipate that this
year will yield great results, with your participation.
In Solidarity,
Clayola Brown, President
A. Philip Randolph Institute
In Unity,
Brittaney Staton, Youth Conference Coordinator
A. Philip Randolph Institute
2015 APRI Y.O.U.T.H Conference Application Packet
Application Instructions
This packet contains all 2015 APRI Y.O.U.T.H Conference Application attachments and
instructions. In order for your application to be considered for review, all components of
this application and its attachments must be submitted via the online application link. Due
to the high number of applicants, the due date for all applications to be received
electronically or by mail is June 12, 2015.
A $50.00 non-refundable application fee is required with every application. Failure to
include this fee will render the application incomplete and will delay the processing time.
Application fees should be mailed to the address below:
A. Philip Randolph Institute
Attn: Brittaney Staton
815 16th Street, NW 2nd Floor
Washington, DC 20006
There are limited spaces available for this year’s conference, so we urge you to apply early
and to follow all application instructions. If you have any questions regarding the
application or the 2015 APRI Y.O.U.T.H Conference, feel free to contact me at
202-508-3714 or email me at brittaney.staton@yahoo.com.
Important Dates
Event
May 4, 2015
Application Period Opens
June 12, 2015
Application Deadline
June 12 - June 19, 2015
Application Reviewed
June 22, 2015
Participants Notified of Acceptance
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2015 APRI Y.O.U.T.H Conference Application Packet
Application Checklist
Indicate the attachments that are completed and included in this application.
Completed Application Checklist
Parent Content/ Liability Waiver
Promissory Note
Activity Waiver & Release Form Agreement
$50 Application Fee
Application Form
Essay
Letter of Recommendation
Photograph
Online 2015 Youth Application Information Form
I____________________________________________ acknowledge that I have included the
(Print Student Name)
indicated attachments above in my 2015 APRI Y.O.U.T.H Conference Application. I also
understand that my application will only be considered for review if all components of this
application are typed, completed and mailed together in one packet.
Signature: __________________________________Date:_________________
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2015 APRI Y.O.U.T.H Conference Application Packet
Parent Content/ Liability Waiver
To be completed by all applicants and parents of applicants who will not be 18 years old by
August 12, 2015.
I will be not 18 years of age by August 12, 2015.
I will be 18 years of age August 12, 2015.
I ___________________________________________ consent to allow my child,
(Print Parent or Legal Guardian Name)
_________________________________________, to attend the 2015 A. Phillip Randolph
(Print Student Name)
Y.O.U.T.H Leadership Conference in Savannah, GA from August 12-16, 2015. I
_______________________________________ agree to give permission to the A. Phillip
(Print Parent or Legal Guardian Name)
Randolph staff to authorize treatment in the case of an emergency.
Parent or Legal Guardian Name: _____________________________________
(Please Print)
Signature: _____________________________________ Date: ______________
Student Name: ____________________________________________________
(Please Print)
Signature: _____________________________________ Date: ______________
Health Insurance Information:
Please have a copy (front and back) of Insurance cards upon arrival.
Carrier:
________________________________________
Name:
________________________________________
Plan Number: ________________________________________
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2015 APRI Y.O.U.T.H Conference Application Packet
Promissory Note
The applicant agrees to repay the cost of his/her airline tickets in the event that they fail to
use the pre-purchased ticket by August 12, 2015. The total cost of the airline tickets shall be
made payable:
A. Philip Randolph Institute
Attn: Brittaney Staton
815 16th Street, NW 2nd Floor
Washington, DC 20006
I _________________________________, for value received, promise and agree to pay on or
(Print Applicant Name)
before August 12, 2015 to the order of A. Phillip Randolph Institute in lawful money of the
United States of America, the principal sum of ______________________________ ‘s airline
(Print Applicant Name)
ticket.
Borrower: ________________________________________Date: ____________
Witnessed: ________________________________________Date:____________
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2015 APRI Y.O.U.T.H Conference Application Packet
Activity Waiver & Release Form Agreement
The Activity Waiver & Release Form Agreement is an agreement between the applicant
and the A. Philip Randolph Institute that releases the party providing an activity (A. Philip
Randolph Institute) from liability claims from the individual wishing to participate in the
activity (applicant). The applicant is required to give up all future claims against the A.
Philip Randolph Institute so care should be taken to ensure that the applicant is fully aware
of his or her rights.
I _____________________________ , the applicant, hereby release the A. Philip Randolph
(Print Applicant Name)
Institute both national and local, it’s staff, agents and affiliates, from any or all claims,
actions, suits, by both litigation, arbitration or the likes, arising from unintended actions
accidents and/or intentional unauthorized and/or unforeseen acts of said staff, agents and/
or affiliates being beyond the scope of the agents’ authority or performed in a manner
below the acceptable standard of care which result in either personal injury of property
damage.
I _____________________________, the applicant, freely and knowingly give this release in
(Print Applicant Name)
order that I may participate in the A.P.R.I Youth Leadership Conference, scheduled from
August 12-16, 2015.
Applicant:
_____________________________________ Date ______________
Witness
_____________________________________Date_______________
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2015 APRI Y.O.U.T.H Conference Application Packet
2015 APRI Y.O.U.T.H. Leadership Conference
Application Form
New Student
Returning Student
Last Name: _______________________________________________
First Name: _______________________________________________
Age:
______ T- Shirt Size:________________ SSN: _____-____-______
Address:
______________________________________________________________________________
______________________________________________________________________________
City: ______________________________ State: _______ Zip Code: _________
Cell # ________________________________ Work# ________________________________
Email address: _____________________________________@______________________
Name of School: ____________________________________________________________
Grade Level:
High School 11
12
(circle one)
College
SO
JR
SR
YES
NO
(circle one)
FR
Degree Completed
(circle one)
GPA: _______________________ Major: ___________________________
Fraternity/Sorority: __________________________________________
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2015 APRI Y.O.U.T.H Conference Application Packet
Please list at least 2 Airports nearest you:
(This will better assist us when making your travel arrangement.)
1. ___________________________________
2. ___________________________________
Emergency Contact Information
1. Name: ___________________________________________________________
Phone: ___________________________________
Relationship: ______________________________
Is this person attending the A.P.R.I Adult conference? YES
NO
(circle one)
2. Name: ____________________________________________________________
Phone: ____________________________________
Relationship: _______________________________
Is this person attending the A.P.R.I Adult conference?
YES
NO
(circle one)
List Allergies: __________________________________________________________
Vegetarian Meals (Optional):
Yes
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2015 APRI Y.O.U.T.H Conference Application Packet
I. Essay Questions:
i. 2 - 3 pages typed
ii. Be sure to include sourced facts to support your claims and opinions
1. New Students:
“Power is the flower of organization.” - A. Philip Randolph
There has been a surge in media coverage regarding police brutality against
minority youth within recent years. Although numerous, peaceful and nonpeaceful, protest have taken place, very little political and legislative action has
been implemented to hold police more accountable. Do you think that the protest
have been effective? Why and Why not? Be sure to explain what organization
means in terms of movements and give an example of how you would organize a
protest. Explain what changes it would bring about and why?
2. Returning Students:
“Strong people don't need strong leaders.” - Ella Baker
Explain and expound upon your understanding of this quote in terms of civil rights
movements and unions. Furthermore, please use this quote to justify whether or
not you believe recent protest against police brutality have been successful.
Remember to include your understanding of effective leadership and how it adds or
takes away from the collective whole.
II. Community Service
1. Please list and describe the community service programs or events you have
participated in since last year.
2. If you have participated with an APRI chapter in any event, please name the chapter
and describe the event.
3. Please list and describe any political campaigning done in regards to: Health Care
Reform, Employee Free Choice Act, or Immigration Reform.
III.1 Letter of Recommendation from one of the following:
1. Current A.P.R.I Chapter Officer *if you are a APRI member*
2. Union Leader
3. Activist
4. Church Member
5. Professor/ Employer
IV. Please provide a photo of only yourself
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