NEW Leadership™ PennsylvaniaSummer Institute 2017 Application June 4, 2017 - June 9, 2017 Contact Information * First Name : * Last Name : Home Phone : (xxx) xxx-xxxx Cell Phone : (xxx) xxx-xxxx * Email Address : Permanent Address : * Address : Address 2 : * City : * State : * Zip Code : Campus Address : (if different from permanent address) Address : Address 2: City : State : Zip Code : Notification should be sent to : PERMANENT address CAMPUS address Academic Information * College/University: * Class Year : * Major/Minor : * Academic areas of interest : List any political science or women’s studies courses that you have taken. Include the semesters during which classes were taken (ex: Fall ’10). List any honors or awards received, as well as leadership positions attained. Personal Background: (Note: completing this section is voluntary) Age : 18-25 26-35 36-45 over 45 Ethnicity : African American Asian Caucasian Latina Other Essay Questions 1. Describe the political or community activities and/or organizations you have been involved with. Which is the most important to you and why? 2. Why do you wish to participate in NEW Leadership™ Pennsylvania? What do you expect to get out of participating in this program? References Provide the names, titles, phone numbers, and e-mail addresses for three references. At least one reference must be a college faculty or staff member. Reference 1 * First Name : * Last Name : * Title : * Phone Number : * Email Address : Reference 2 * First Name : * Last Name : * Title : * Phone Number : * Email Address : Reference 3 * First Name : * Last Name : * Title : * Phone Number : * Email Address : Program Fee Each participating college and university is asked to pay a program fee of $300 per student. Housing, food, and all program materials are provided for the full six days of the program. There is no direct cost to the students. Please contact the PCWP if you have any questions at (412) 365-1878 or firstname.lastname@example.org. Please indicate below if you have a contact at your school who has agreed to sponsor you or assist you in obtaining funding for the program fee. I have contacted a faculty/staff member who has agreed to assist me in obtaining funding to cover the $300 NEW Leadership™ program fee. Faculty Contact Information First Name : Last Name : Title : Phone Number : Email Address : Credit Option I am interested in obtaining two credits for my NEW Leadership™ Pennsylvania experience. I understand that the cost is $829/credit. I will contact the PCWP (email@example.com) for instructions on how to enroll in this course. I am responsible for payment to Chatham University for these course credits associated with NEW Leadership Pennsylvania™. [The program fee does not cover the course credits for NEW Leadership™ Pennsylvania.] So that we can improve our program outreach, please tell us where you heard about NEW Leadership™. NEW Leadership™ Pennsylvania participants are expected to attend all summer institute sessions and live in the residence halls during the entire program June 4 – June 9, 2017. In completing this application, you acknowledge that you are aware of these requirements and agree, if accepted, to make every effort to meet this commitment.