Roosevelt Connections Program Application

SEM 2 Roosevelt Connections Crew REGISTRATION!

Thanks for your interest in for the Connections Program!
- Connections is a year long program supporting a more inclusive and connected school community.
- Together, a diverse group of 14 students (Crew) make friends while doing fun activities, interactive workshops and inspirational field trips.
- That same group then leads activities for other students promoting a sense of belonging in their school.
- Crew members develop leadership skills, meet new friends, and leave a lasting impact on their school community.
Students also earn 60 Service hrs upon completion!

Please feel free to reach out to Ms. Amber:
- Via email acinwood@seattlepublicschools.org
- Txt/call (206) 837 2026
- Or visit the Career Center Room 110 Mon/Tues/Weds.
To learn first hand about being part of the program, find one of our Connections Crew Members... Ivan Smith, Victoria Venegas, Aaron Batho, Sarah Dahham, Bella Komba, Milla Wright-Hong, Julia Waltar & Chebar Mukwaya
Please complete all applicable and/or required fields!
Please select the student's current grade level:*

Grade 9Grade 10Grade 11
The ULMS Connections program is part of the National Urban League Project Ready (https://nul.org/program/project-ready) which prepares youth and young adult for college, work and life. Would you be interested in learning about other project ready programs? Other ULMS support and programs?

Yes, please!No, thank you.
PROGRAM REQUIREMENTS:

Semester 2, 2024-2025

February 20th - June 5th, 2025
- 1 Mid Winter Break Field Trip - Thurs February 20th, 2025. 10am - 3:30pm
- Program Orientation - Thurs February 27th, 2025. 4-6pm RM 110
- Weekly Meetups - every Thurs 4-6pm at RM 110
- 3 Spring Break Field Trips - Weds to Fri April 16 - 18, 2025. 10am - 3:30pm
- Semester 1, 2025-26
- Plan and facilitate up to 4 student led activities (funded) with a diverse group of 12-20 school peers. Activities are planned as a team (Crew).
- You will also need to meet on a regular basis with your Crew to plan.
Can you make the above time commitment to the program?*

YesNo
Personal Information
Name*

First NameLast Name
Nickname
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Primary Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School(s) attended (High School and/or Colleges)*
What soft skills do you have?*

CommunicationTime-ManagementTeam PlayerSelf-StarterAdaptabilityLeadership SkillsProfessionalismDetail-OrientedCreativePassionateEmpathyOther
In no less than 5 sentences, why do you want to be a part of the Connections Program?*
In no less than 5 sentences, name a time at school when you felt included. How did it feel? What did the people do around you do to make you feel included.*
I would like to help others in my school feel like they belong by....*
Please list a Teacher or School Counselor that can be a reference for you (don't forget to ask them!)
Please provide the name and email of a Teacher or School Counselor that can be a reference for you (don't forget to ask them!)
SCHOOL REFERENCE NAME: Please provide the full name of a teacher or school counselor etc. *

First NameLast Name
SCHOOL REFERENCE EMAIL: Please provide teacher or school counselor etc. contact email*
example@example.com
CHECK ONE: Have you earned any of your required Service Learning Hours?*

YesNoSome
How did you learn about the Connections Program?*

Word of MouthULMS Social MediaULMS WebsiteULMS Employee or Program ParticipantULMS NewsletterTeacherSchool CounselorFlyerSPS EmailFrom a Crew MemberSchool AnnouncementsOther
Demographic Information
‘The Connections Program aims to honor participants identity(s) and recognize that it is individual and complex. Though only a part of who we are, the following demographic questions are to help us support participants throughout the program by providing respectful spaces and activities, food options etc.’
How do the you define your gender identity?*

FemaleMaleNon-binary or Non-ConformingPrefer not to disclose.Other
Preferred Pronouns*

She/HerHe/HimThey/ThemPrefer not to disclose.Other
Race/ethnicity?*

Indigenous/Native AmericanWhiteBlack/African AmericanBlack/African DescentHispanic/Latino - Puerto RicanHispanic/Latino - Latino-DominicanHispanic/Latino - MexicanHispanic/Latino - Central AmericanHispanic/Latino - OtherAsian - SouthAsian - EastAsian - South EastNative Hawaiian or Other Pacific IslanderMultiracialOther
If you listed multiracial, please list
If you listed other, please list and/or describe
Ethnic and Cultural Identity?
Please complete this sentence (include religion if any): My ethnic and cultural identity is...
*Note: People who identify with the same ethnic and cultural group often share the same traditions, food, languages, cultural and religious practices. For some people their race and ethnicity might be the same; for others they might be different.
Prefer not to answer
Parent/Legal Guardian Information
Parent or Legal Guardian Name*

First NameLast Name
Relationship to the Student*

MotherFatherGrandparentSiblingAuntUncleLegal GuardianOther
Address (if different from the youth)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Can this number receive text messages?*

YesNo
Email Address*
example@example.com
Do you understand, acknowledge, and affirm the certification statement above?*

Yes

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SEM 2 Roosevelt Connections Crew REGISTRATION!

Please complete all applicable and/or required fields!

Personal Information

Demographic Information

Parent/Legal Guardian Information

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