CIVIC EDUCATION PROJECT • NORTHWESTERN UNIVERSITY

CivicWeekend
Spring 2008
for Jack Kent Cooke Foundation Higher Education Scholars

Registration Form



Instructions

1. Review all the information available on the CivicWeekend program pages (click to review program information) then complete the fields below and submit your registration at the bottom of this page. Fields marked with a * are required.

2. Participants will be registered on a rolling basis, so we encourage participants to register early. Registered participants will receive an informational packet via e-mail a few days after registering. The packet will contain all relevant information about the program, including a detailed schedule, travel information, things to bring, program policies, etc.

3. Registrations will be processed on first come, first served basis. As such, we encourage Scholars to register as soon as possible. Registrations will not be processed after February 15, 2008.

Thank you for your interest in the CivicWeekend program. With questions about the program for Jack Kent Cooke Higher Ed Scholars, to check on the status of your registration, or if you are experiencing difficulties with the online application, please contact us at (847) 467-2572 or cep@northwestern.edu.

PARTICIPANT INFORMATION


Title * Middle Name *
       
Date of Birth*
/
/
 
MM
DD
YYYY
  
           
Mailing Address*
  Number and Street Address
 
  City State Zip
       
Home Phone*  Cell Phone E-Mail* 
     
Gender*    Female    Male
     
Race/Ethnicity*

 

EMERGENCY CONTACT INFORMATION

Please specify an emergency contact  
Title* First Name*
     
Day Phone* Evening Phone*  Cell Phone
     
Relationship to Participant*   

 

PROGRAM HISTORY

Have you previously participated in a program of the Civic Education Project or the Center for Talent Development?*
   Yes
   No
Which Program? Last Year Attended
     
 
How did you first hear about CivicWeekend?*
 
Note


ACADEMIC/EMPLOYMENT INFORMATION

Current School or Workplace
  Name* City* State*
School-year Status*    
       


PROGRAM PREFERENCE

Please indicate the program for which you are applying.
 
Top Choice* 


PARTICIPANT HONOR CODE

The Civic Education Project takes every reasonable step to ensure the safety of our participants and staff. However, participants must willingly follow certain guidelines to contribute to a safe working and learning environment. We ask that participants act responsibly and maturely at all times, and follow a strict code for participant conduct. In order to create a safe and successful learning community, I agree to:

• Attend all CivicWeekend activities, be on time, and participate fully
• Always act with honesty and personal integrity
• Treat all participants, staff, and community members with respect, regardless of their race, culture, religion, age, gender, ability, or sexual orientation
• Treat all facilities and property with respect and care
• Remain alcohol and drug free during the weekend
• Observe all program rules and cooperate with staff

I understand that if I fail to live up to these expectations for behavior, I may be dismissed from the program, and sent home at my own expense.


CERTIFICATION

I have read the CivicWeekend materials and honor code and agree to the requirements stated in such materials and established during the session by staff. The signature below also grants Northwestern University the right to reproduce the participant’s image, likeness, or participant work in public relations publications and other media. I will make no monetary or other claim against Northwestern for such use. I certify that all statements and materials presented in the registration process are correct and complete, and agree that the knowing submission of inaccurate, incomplete, or misleading statements or materials constitutes grounds for revocation of registration or dismissal from the program.

The participant must type his/her name and the current date below to certify the above statement.
     
Certified by:
  Participant Full Name* Date*
     

Completing Your Application

Please Note: When you click on the "Confirm Registration " button below, your completed Registration Form will be sent via email to cep@northwestern.edu, and a screen confirming the information you submitted will appear. If you need to revise or edit any parts of your registration after sending, please contact CEP at (847) 467-2572 or cep@northwestern.edu.

Civic Education Project
617 Dartmouth Place, Evanston, Illinois, 60208-4175
Phone: (847) 467-2572, Fax (847) 491-3394, E-mail: cep@northwestern.edu