2015-2016 APILR MENTOR APPLICATION: January 22-24, 2016
*Note: People applying to APILR as a first-time Participant should fill out another form*

APILR Background
The 22nd Annual Asian Pacific Islander Leadership Retreat (APILR) empowers students with the necessary leadership skills and resources to make a difference on campus and in their communities through an examination of self-identity, current API community issues, and an application of skills to the communities. This will be accomplished through workshops and activities focused on self-awareness and self-application. Mentors serve as group facilitators as well as community resources to APILR participants. Mentors will facilitate debrief, uphold APILR community agreements and assure safety of APILR attendees. Lastly we encourage mentor to foster relations with participants well after the retreat as a continued resource.

Application Deadline
Applications are available as a Google form or word document, and both can be found on the Cross Cultural Center website: http://ccc.ucdavis.edu/apilr.html. Paper applications can be emailed to davisAPILR@gmail.com or printed out and dropped off at the Cross Cultural Center (CCC). Please submit your application by Monday, November 2, 2015 to be considered. All applications submitted after this time will be taken into consideration only if there is space available.

Selection Criteria
Mentors for APILR are in charge of leading small groups in discussions and activities, as well as helping build community during the course of the weekend. There will be a required 2-3 hour one-time training prior to APILR for all mentors. The selection committee will review applications and inform applicants via email or phone on November 16, 2015. Please email davisAPILR@gmail.com if you do not receive a notification. Individuals selected to participate are required to pay a $30 registration fee or submit a fee waiver with their application by November 25th, 2015 in order to keep their spot. Individuals not selected in the first round will be placed on a waiting list.

Registration Fee and Liability
If you are selected to attend there will be a participation fee of $30. Further instructions will be announced later regarding payment. You will be required to fill out the Waiver of Liability form when you submit your NON-REFUNDABLE and NON-TRANSFERABLE payment. Participation fees include transportation, room and board, and all retreat materials.

Itinerary
Friday. January 22nd, 2016: The bus will depart from UC Davis to the retreat site on Friday afternoon. The estimated time of arrival will depend on pending traffic. More details about departure will be given at a later time.
Sunday. January 24th, 2016: We will depart from the retreat site at approximately 2:00pm and should be back to the UC Davis campus no later than 4:00pm

Please Note
Students will not be permitted to drive themselves to the retreat site. You must travel via charter bus with the group, so please plan accordingly.

If you would like a letter verifying your participation for an academic or work related reason, please notify Fong Tran at: fntran@ucdavis.edu at least two weeks before you need the letter.

Contact Information
If you have any questions or please call the following contacts:

Mandy Lew
APILR/APCW Student Coordinator
mglew@ucdavis.edu

Katelyn Dixon
APILR/APCW Student Coordinator
kedixon@ucdavis.edu

Fong Tran
CCC Program Advisor/Coordinator
fntran@ucdavis.edu

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General Information
First Name *
Last Name *
MI:
Email: *
*UC Davis email preferred*
School Year *
Required
Gender *
Preferred Pronouns *
Ethnicity *
Major *
Minor *
Affiliated Organizations (List any orgs you have been a part of, including leadership roles if applicable): *
T-Shirt Size *
Sleeping and shower accommodations at the site are gender neutral. Will you need gender-specific accommodations?   *
Reduced Fee Waiver:
Reduced Fee Waivers are a way to help students with financial constraints pay for the cost of this retreat. If needed, explain your reason for requesting this waiver.
Emergency Contact Information
Please list someone who is not also attending the retreat, and who would be able to make medical decisions for you in case of emergency.
Primary Emergency Contact: *
Phone Number: *
Relationship to Applicant: *
Secondary Emergency Contact: *
Phone Number: *
Relationship to Applicant: *
Health Information
Are there any health concerns/ Special needs that we should be aware of? *
Allergies to Food or Medication? *
Do you have any dietary restrictions? *
If so please indicate:
Clear selection
Do you have any other dietary needs? If yes, please explain.
Please answer the following questions to the best of your ability.
Why do you want to be a facilitator at the Asian Pacific Islander Leadership Retreat (APILR)? *
(450 characters minimum) *please note the difference between the number of characters and the number of words*
Briefly describe your former experience as a facilitator or participant in a conference/workshop setting. *
(450 characters minimum)
What topics and/or issues are you most interested in discussing during APILR? *
(450 characters minimum)
How will you contribute to other participants’ experiences at the leadership retreat in order to make sure everyone participates and enjoys their time? *
(450 characters minimum)
Please Note: Mentors are required to attend one of the two trainings on these dates: January 11th (Monday) and 12th(Tuesday) from 6:00-9:00pm. Both will take place in Room E.
Which APILR Mentor training will you be attending? *
Required
Have you ever attended APILR before as a participant? *
Required
Have you ever attended APILR before as a mentor? *
Required
Have you ever attended any other retreat? (i.e. REACH Retreat, SEA retreat, etc.) *
If yes, please list the retreats:
Required
If yes, please list the retreat(s) attended:
Would you like to be added to the Cross Cultural Center’s list serv in order to receive information about campus resources and events? *
Statement of Agreement
If I am selected to participate, I agree to follow all University Policies and guidelines including support for the principles of community, abstaining from alcohol consumption, and engaging in the use of illegal drugs while attending the conference. Furthermore, I understand that I am committed to attending the entire retreat. Early departure will not be allowed unless there is an emergency.
Participant Signature: *
(Write out full name)
Date *
By typing your name on the signature line, you verify yourself as the named applicant and agree to all information and policies outlined in this application.

**lf under 18 years of age, a signature of parent or guardian is necessary**
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