V. TEAM MEMBERS
Each member of your team including the graduate mentor team member must complete a copy of this
section, sign the endorsement, and submit an unofficial copy of a current academic transcript.
Project Title:
Name:
Student ID #:
Cellphone:
Academic Advisor (Department’s Director of Graduate Studies for Graduate Mentor):
Academic Advisor’s E-mail Address:
Statement of Purpose
Describe your role on this team and what you expect to contribute to this proposed JPC project.
Include any prior community engagement and service, related coursework, and/or participation in
workshops, lectures, and special training.
(Maximum 200 words)
Goals
Please list three learning goals for yourself that you hope to reach by the end of the JPC project:
Please three goals you have for the JPC project:
V. Team Members
Team Member Endorsement
Please initial each of the following statements and sign below:
I will be a fulltime undergraduate or graduate student enrolled at the University of Virginia through the
2016-17 academic year. __________
I promise to adhere to all JPC Award procedures, including the submission of my mid-term report,
final project, and presentation. __________
If the project involves human and/or animal subjects, I will seek advice from my faculty advisor, and I
will comply with the policies of the University’s Institutional Review Boards. __________
If the proposed JPC project involves international travel, I understand that:
I may not travel to any location with a U.S. State Department Travel Warning and, if such a warning is
issued while I am abroad, I must leave the country immediately in the safest manner possible.
(http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html). Prior to my departure, I will register with the
International Studies Office, attend a pre-departure orientation, and comply with any other ISO
requirements. www.virginia.edu/iso. __________
I am responsible for obtaining a visa and/or work or other permit required for my intended destination.
__________
I am responsible for getting appropriate inoculations and overseas health/emergency
coverage.__________
If I am an international student, I will consult with an international student advisor about my visa
status. __________
_______________________________________________________________
Signature of JPC Team Member
____________________________________
Date of Signature
Insert an unofficial copy of your current academic transcript behind this page.
V. Team Members