Depauw University Bonner Scholars Program s1

Pacific Islander Student Center SUMMER BRIDGE PROGRAM

PARTICIPANT CONFIRMATION FORM

Please visit the Pacific Islander Summer Bridge Program website (http://hilo.hawaii.edu/pisc/programs/bridge.php) before confirming your participation in the program. Complete this form and send, fax, or email it to the Pacific Islander Student Center (see instructions at the end). We recommend that you complete this form on a computer, save a copy, and email it to [email protected].

SUBMISSION DEADLINE: June 30, 2012.

STUDENT INFORMATION

Last Name First Name

Mailing Address (PO Box) City State Zip

Phone Email

Which island (nation) are you from? (check all that apply):

___Chuuk ___Pohnpei ___Kosrae ___Yap ___Samoa ___Tonga ___Guam

___Marshall Islands ___Palau ___Saipan ___Tinian ___Rota ___Other (specify ______)

OTHER WAYS TO CONTACT YOU NOTE: We will need to get in touch with you during the preparation time. If you do not have an email or phone, please give us the name and contact information of a reliable relative, neighbor, or friend who can pass information on to you.

Full Name of Secondary Contact Telephone Number

Mailing Address (PO Box) City State Zip ___ Relative ___ Neighbor ___ Friend Email

HOUSING NOTE: During the week-long Pacific Islander Summer Bridge Program, all participants will be staying in the dorms at the University of Hawaii at Hilo. At the conclusion of the program, participants will move to their self- arranged housing. Those who have applied for and were approved for UH Hilo Student Housing will be able to move directly into their assigned room. All others will need to move to their housing.

After the program is over, I intend to stay (check one): ___ UH Hilo Student Housing ___ Relatives ___ Friends

Have you applied for UH Hilo Student Housing? ___Yes ___No

Pacific Islander Student Center (PISC) at UH Hilo 1 Visit our website: http://hilo.hawaii.edu/pisc Pacific Islander Student Center SUMMER BRIDGE PROGRAM

PARTICIPANT AGREEMENT NOTE: In order to confirm your participation, you must attach a copy of your confirmed airline reservation to this form or email it to Desha Staley-Raatior ([email protected]). Please make your flight arrangement to fly into the Hilo International Airport (ITO) anytime on Saturday, August 4, 2012 or no later than 4 PM on Sunday, August 5, 2012. We will meet you at the baggage claim and transport you to campus.

I ______(print full name) hereby confirm my participation in the Pacific Islander Summer Bridge Program at the University of Hawaii at Hilo. I understand that in order to be a confirmed participant, I must submit this completed form along with proof of a confirmed / paid airline reservation arriving in Hilo by the dates stated above.

By signing below, I commit to participate fully in all planned programs and activities to help me succeed at the University.

Arrival Date Arrival Time Airline Flight Number

Signature Date

Note: If you are emailing this form, please type your name on the signature line.

ANY QUESTIONS? Please add any questions here or email Desha Staley-Raatior at [email protected].

SEND TO:

Please send, fax, or email the completed form to:

Desha Staley-Raatior Pacific Islander Student Center, Campus Center 307 University of Hawaii at Hilo 200 W. Kawili St., Hilo, HI 96720-4091

Pacific Islander Student Center (PISC) at UH Hilo 2 Visit our website: http://hilo.hawaii.edu/pisc Pacific Islander Student Center SUMMER BRIDGE PROGRAM

Phone: 808-974-7616 | Email: [email protected] | Fax: 808-974-7691

Pacific Islander Student Center (PISC) at UH Hilo 3 Visit our website: http://hilo.hawaii.edu/pisc