SOUTHEAST ASIAN O RGANIZATIONS PRESENTS:
SOUTHEAST ASIAN ADMIT WEEKEND 2017
308 Westwood Plaza/413 Kerckhoff Hall
Los Angeles, CA 90095
[email protected] | (323) 786-2732
Hello Prospective Bruins,
Congratulations! On behalf of the Southeast Asian Organizations at UCLA, we personally
applaud you on your acceptance to the University of California, Los Angeles. You will be
receiving a phone call from a representative of our organization this week to tell you about
our upcoming event. We cordially invite you to attend our 9th Annual Southeast Asian
Admit Weekend from Thursday evening, April 13th to Sunday afternoon, April 16th, 2017,
hosted by the Southeast Asian Organizations: Vietnamese Student Union, United Khmer
Students, Thai Smakom, and the Association of Hmong Students. The award-winning, free
weekend is guaranteed to be full of networking opportunities, resources, and fun as we
welcome you into our Bruin family. You will have a great opportunity to learn about life as a
Southeast Asian student at UCLA and meet other admitted Southeast Asian-American students,
current UCLA students, faculty, and alumni.
We will have various bus pick-up locations in Orange County and vans for the Los Angeles
County. Students who need transportation from outside these areas can apply to our Travel
Scholarship. Please visit our website at www.seaadmit.com to receive more information about
the Travel Scholarship, and to receive continuous updates about the application process. If you
have any other questions or concerns about the weekend or UCLA in general, please do not
hesitate to contact any of the individuals listed by either calling (323) 786-2732 or e-mailing
[email protected]. Remember, the deadline to make your reservation for the weekend and
for travel is: March 31 st, 2017 by 11:59 PM. Once again, the Southeast Asian Organizations
would like to congratulate you for your achievements. We look forward to meeting you in person!
Thank you,
Christine Pham
SEA Admit Weekend Co-Chair
Connect with us!
Danny Pham
SEA Admit Weekend Co-Chair
Michael Ly
SEA Admit Weekend Co-Chair
SOUTHEAST ASIAN O RGANIZATIONS PRESENTS:
SOUTHEAST ASIAN ADMIT WEEKEND 2017
308 Westwood Plaza/413 Kerckhoff Hall
Los Angeles, CA 90095
[email protected] | (323) 786-2732
Personal Information
Name
Mailing Address
City/State/Zip
T-Shirt Size (Adult S/M/L/XL/XXL)
CLICK DROPDOWN TO SELECT
Home Phone
Student E-Mail
UC Application UID
Cell Phone
Text Messaging
Date of Birth (mm/dd/yyyy)
Parent E-Mail
Gender
Ethnic background (e.g., Chinese, Vietnamese, Burmese, Thai, Cambodian, Teochew, Hmong)
Best form of contact (Check all that apply)
E-Mail
Text
Phone
Best time to contact (e.g. 10:00AM-4:00PM; 9:00PM-10:00PM )
Method of Transportation
If Self-Provided, Please Specify
CLICK DROPDOWN TO SELECT
CLICK DROPDOWN TO SELECT
Other (please indicate below)
If you (or your relative) are driving, are you willing to drive other
admitted students in your area? ( If yes, please list # of people you can drive) CLICK DROPDOWN TO SELECT
High School Information*
Name of High School
Year of Graduation
Address
City/State/Zip
High School GPA
Class Ranking (e.g., 10/150)
SAT Score
Reading
Math
Writing
Have you taken any dual enrollment/AP courses?
ACT Score:
English
Math
▢YES ▢NO
*If you plan on driving yourself to SEA Admit Weekend, parking is $12/day, and we are unable to reimburse you
SOUTHEAST ASIAN O RGANIZATIONS PRESENTS:
SOUTHEAST ASIAN ADMIT WEEKEND 2017
308 Westwood Plaza/413 Kerckhoff Hall
Los Angeles, CA 90095
[email protected] | (323) 786-2732
Household Information*
Who do you live with?
One Parent
Two Parents
Are you the first one to attend college?
CLICK DROPDOWN TO SELECT
Grandparents
Other (please specify)
Number of Siblings
Number of Siblings in College
Parent/Guardian 1
Name
Parent/Guardian 2
Name
Occupation
Occupation
Highest Level of Education
Highest Level of Education
Amount family makes a year (optional)
*This information is used for demographic purposes only and will not be considered in your application
Financial Information
How are you planning to pay for college? Check all that apply.
▢Financial Aid
▢Self-Pay or Parents
▢Educational Loan
▢Other: (please specify)
College Information
Do you plan to attend UCLA?
Have you submitted a SIR to another college?
CLICK DROPDOWN TO SELECT
CLICK DROPDOWN TO SELECT
What other colleges have you been admitted to? Please list.
1
2.
3.
4.
5.
Intended major in college
Intended career/profession
SOUTHEAST ASIAN O RGANIZATIONS PRESENTS:
SOUTHEAST ASIAN ADMIT WEEKEND 2017
308 Westwood Plaza/413 Kerckhoff Hall
Los Angeles, CA 90095
[email protected] | (323) 786-2732
Essay – IMPORTANT! Please be thoughtful in your response.
In 300 words or fewer, explain what you want to get out of attending the SEA Admit Weekend at UCLA.
Include information about any special circumstances or challenges that you would like the committee to take into
consideration in reviewing your application. What are your expectations for the event, i.e. what issues concern you most,
what would you like to see? You may attach a separate word document if needed.
What would be some reasons why you would choose or not choose UCLA?
Alumni Dinner Question!!
On FRIDAY April 14, 2017, we will be have an alumni dinner, please indicate your meal preference:
Click down for options
Talent Show Sign-Up (Optional)
SEA Admit will have a talent show during the weekend on Saturday, April 15th from 8PM-10PM. If you are interested in showcasing your
talent, please describe your performance and any technical support you may need.
What act will you be performing?
Do you need technical support?
What will you need for your performance? (e.g. microphones, etc.)
CLICK DROPDOWN TO SELECT
Please be aware that it will be difficult to accommodate for religious services on S unday. By submitting this application, you agree
to fully attend the S EA Admit Weekend and, if applicable, will make your own arrangements with us prior to the weekend.
Student Signature
Parent/Guardian Signature
(REQUIRED regardless if participant is over 18)
____________ Date _______________
Date _______________
HOW TO SUBMIT THIS APPLICATION
1. Email to [email protected] with the subject line: SEA Admit Application for (YOUR NAME)
2. Attach the PDF application with it renamed like the following: LASTNAME_FIRSTNAME
UNIVERSITY OF CALIFORNIA LOS ANGELES
Waiver of Liability, Assumption of Risk, and Indemnity Agreement Waiver
Participant's Name (please print): _______________________________________________
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
In consideration of being permitted to participate in any way in Southeast Asian Admit Weekend hosted
by the UCLA Vietnamese Student Union on Thursday, April 13 – Sunday, April 16, 2017 hereinafter
called "The Activity", I, for myself, my heirs, personal representatives, or assigns, do hereby release,
waive, discharge, and covenant not to sue The Regents of the University of California, its officers, employees,
and agents and the UCLA Vietnamese Student Union and its agents, from liability from any and all claims
including the negligence of The Regents of the University of California, its officers, employees and agents,
and the UCLA Vietnamese Student Union and its agents, resulting in personal injury, accidents or illnesses
(including death), and property loss arising from, but not limited to, participation in The Activity, and the use of
facilities, premises or equipment.
_________________________________________
Signature of Parent/Guardian of Minor
Date
____________________________________________
Signature of Participant
Date
Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated
regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range
from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint
or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are
inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all
such risks.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the University of
California and the UCLA Vietnamese Student Union HARMLESS from any and all claims, actions, suits, procedures,
costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in The
Activity and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement
is intended to be as broad and inclusive as is permitted by the laws of the State of California and that if any portion
thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity
agreement and fully understand the terms. I understand that I am giving up substantial rights, including my
right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be
a complete and unconditional release of all liability to the greatest extent allowed by law.
I am an adult, 18 years or older, and I have read and understand this agreement and I freely and knowingly give my
consent to The Regents of the University of California as described herein.
________________________________________
Signature of Parent/Guardian of Minor
Date
Participant's Age (if minor) _______
____________________________________________
Signature of Participant
Date
EMERGENCY INFORMATION & TREATMENT CONSENT FORM
I.
Participant Information
Name_______________________________________________________________________________Age_________
Address________________________________________________________________________________________________
City________________________________________________________ State _______________ Zip _______________
Phone___________________________________________________ Email________________________________________
II. Family Information (if participant is a minor)
Parent/guardian (First/Last/MI) _________________________________________ Home Phone _______________Cell Phone____________
Address_______________________________________________________Employer ______________________________
Work Phone ________________________Work Address_______________________________________________________
Parent/guardian (First/Last/MI) ________________________________________ Home Phone ___________ Cell Phone______________
Address_____________________________________________________Employer _____________________________________
Work Phone ________________________Work Address_________________________________________________________
Parent E-mail ____________________________________
III. Health Information
Participant’s Physician________________________________________________________Phone________________________
Address _____________________________________________Insurance Co.________________________________________
Employer group #____________________ Policy Holder Name _____________________________________Member #___________
Please advise us of any learning disabilities, emotional or physical conditions to assist us in providing the best experience for the participant.
Medications that the participant may need:
Medication allergies - Describe reaction and management of the reaction:
Food and Other allergies - include insect stings, hay fever, asthma, animal dander, etc. – Describe reaction and management of reaction:
IMPORTANT: PLEASE READ AND SIGN BELOW. If the participant is a minor, a parent or guardian must
read and sign below.
Informed Consent for Emergency Treatment: In the case of an emergency and if I can not be reached, I authorize the staff of
UCLA to obtain whatever medical treatment they deem necessary for the welfare of my child. I further understand and agree that I
will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment regardless of whether or
not my medical insurance would cover such charges and fees. This consent will remain in force for duration of the program.
Participant Name (print): _________________________________________
Signature: _______________________________________________ Date: _________
I am the parent or legal guardian of the minor_________________________________________, and I am signing on behalf of said
minor.
Name of Participant
Parent/Guardian (print): ___________________________________________
Signature of Parent/guardian_________________________________ Date__________
Student Initiated Yield Weekend 2017 - Code of Conduct
The purpose of the Student Initiated Yield Weekend 2017 is to give students admitted to UCLA the
opportunity to immerse themselves in the university setting. This Code of Conduct is important for establishing
a common level of expectation for program hosts and admitted students so that all are supported in reaching
their highest potential. Just as the program coordinators have established high expectations of their staff and
volunteers, equally high expectations exist for all admitted students. The following is a statement of minimum
expectations regarding the conduct of those participating in the Student Initiated Yield Weekend 2017:
1. Student will show exemplary respect for all private and public property to assure that nothing is done to
cause damage. It is understood that should any damage occur, the person(s) responsible will be held
accountable for damages incurred.
2. Students will refrain from behavior which could lead to physical or emotional harm to others.
3. Students will follow carefully the directions of their program coordinators and will not take exception to
the order or agenda for an event.
4. Students will show respect for peers, UCLA students, volunteers, staff, and faculty throughout the entire
program. Discrimination on the basis of sex, race, color, creed, religion, national origin, sexual
orientation or disabilities will not be tolerated. Accordingly, students will refrain from libel, slanderous
remarks, and obscenity in verbal and written expression.
5. Students will be supervised by their hosts and volunteers during their stay in the volunteer host’s place
of lodging and by program coordinators, staff, and volunteers during their participation in the Student
Initiated Yield Weekend 2017.
6. Students will respect the comfort of other guests in the program as well as other residents and neighbors
in the host’s place of lodging by refraining from being noisy after 12:00 AM.
7. Students, members, volunteers, and guests will refrain from drinking any alcoholic beverages or using
recreational drugs, including tobacco in individual rooms or in public. Those found violating the Code
of Conduct in relation to alcoholic beverages, drugs, and/or tobacco will be dismissed from the
program and may be referred to the Dean of Students.
8. Students will dress in a manner that meets reasonable standards of respect, health, and safety at all
scheduled weekend events.
9. Students must not leave their program’s scheduled events for any reason. In case of an emergency,
students must immediately communicate with their assigned program coordinator to make the
appropriate arrangements.
10. Students will be punctual and present at all scheduled weekend events associated with their program.
Students, parents, volunteers and other participants of the Student Initiated Yield Weekend are all
expected to support this Code of Conduct. Violations of this code can threaten the security of a student’s
admission offer and will have serious consequences for current UCLA students involved in the violation.
In the event that a student does not comply with this Code of Conduct, program coordinators will immediately
communicate with the UCLA Dean of Students Office to establish appropriate action. The signatures that
follow affirm support for this Code of Conduct during Student Initiated Yield Weekend 2017.
Student:
__________________________________________________________________________________________
Print Name
Sign
Date
If you will be under 18 on April 13, 2017, please have a parent/guardian sign below:
__________________________________________________________________________________________
Print Name
Sign
Date
University of California, Los Angeles
MULTIMEDIA RELEASE FORM
Permission for Use of Name, Image and Statements
I hereby grant to The Regents of the University of California permission to reproduce my name,
likeness, identity, voice, photographic image, videographic image and oral or recorded
statements in any publication of The Regents of the University of California intended for
research, educational, promotional, fund-raising or other related use, including but not limited to,
film broadcast, printed publications, webpages and web-based publications, associated with
UCLA.
By signing this form, I waive and release The Regents of the University of California and its
officers, agents and employees, from any claim or liability relating to the use of my name,
likeness, identity, voice, photographic image, videographic image and oral or recorded
statements.
I acknowledge that The Regents of the University of California will rely on this permission and
release in producing, broadcasting, and distributing materials containing my name, likeness,
identity, voice, photographic image, videographic image or oral or recorded statements, and that
I will receive no money or remuneration of any kind from The Regents of the University of
California related to this permission and release or the materials covered by this permission and
release.
Acknowledgment of Understanding:
I have read the above “Permission for Use of Name, Image and Statements” and I fully
understand the terms. I understand that I am giving up substantial rights, including my right to
sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my
signature to be a complete and unconditional release of all liability to the greatest extent allowed
by law.
I am an adult, 18 years or older, and I have read and understand this agreement and I freely and
knowingly give my consent to The Regents of the University of California as described herein.
Participant Name (print): _________________________________________
Signature: _______________________________________________ Date: _______
IMPORTANT: IF THE PARTICIPANT IS UNDER 18 YEARS OF AGE, A PARENT OR
GUARDIAN SIGNATURE IS REQUIRED:
Parent/Guardian Name: _____________________________________
Parent/Guardian Signature: __________________________________ Date: _______
Participant's Age (if minor) ______________