Student Application

Student Application - 2024

Accepting applications now

This application must be completed for each student.

It requests information our funders will use to monitor the program’s success and determine whether to fund this academic program.
ELOC will not sell or share information that reveals your child’s identity.
Each child will have an ID code to collect class-related information. (See instructions below).

"*" indicates required fields

Enrollment Site*

At which site is your child registered?

Child Name*

First Last

Parent / Legal Guardian Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email*

Phone*

Child’s Race*

Black/African American

Native American

White/Caucasian

Native Hawaiian/ Other Pacific Islander

Asian/Asian American

Child’s Ethnicity*

Hispanic (A person from South, Central American, or Caribbean who speaks Spanish)

Not Hispanic

Child’s Gender*

Male

Female

Trans

Family Income*

Less than $49,999

Between $50,000 and $99,999

Between $100,000 and $149,999

Between $150,000 and $199,999

$200,000 or more

Prefer not to answer

Did your child participate in any other ELOC programs? Please check all that apply*

2021

2022

Never Attended Before

CHILD CAREER CHOICES

We want to ensure that we expose your child to careers of interest. Please read all the options here to have an understanding of the career potential of each and select the top three categories in which your child has an interest.

Health Care - Doctor ($252,480), Nurse ($82,750), Paramedic ($49,500), Physician Assistant ($119,460), Social worker ($57,880), Veterinarian ($109,920)7, Athletic trainer ($48,000), Audiologist ($79,000), Cardiac sonographer ($78,000), Cardiovascular invasive specialist ($61,000), Cardiovascular perfusionist ($128,000), Central service technician ($42,000), Dietitian ($62,000), Nurse anesthetist ($196,000), Nurse midwife ($113,000), Nurse practitioner ($121,000), Orthoptist ($100,000), Pharmacist ($129,000), Pharmacy technician ($37,000), Physical therapist ($96,000), Physician Assistant ($122,000), Radiation therapist ($83,000), Surgical technologist ($49,000), Surgical first assistant ($48,000), Recreational therapist ($48,000)

Agriculture, Food, and Natural Resources - Food Science Technician ($41,230), Conservation Scientist and Forester ($62,410), Logging Equipment Operator ($42,060), Soil and Plant Scientist ($69,860), Natural Sciences Manager ($129,100)

Architecture and Construction - Architect ($80,750), Construction Laborer ($36,000), Electrician ($56,180), Civil Engineer ($87,060), Surveyor ($63,420)

Arts, Audio/Video Technology, and Communication - Art Director ($94,220), Reporter, Correspondent, and Broadcast News Analyst ($43,490), Graphic Designer ($52,110), Photographer ($36,280), Editor ($61,370)

Business and Finance - Account ($77,000), Human Resources Manager ($116,720), Bookkeeping, Accounting, and Auditing Clerk ($41,230), Financial Analyst ($85,660), Administrative Services Manager ($96,940), Loan Officer ($63,270)

Education and Training - Instructional Coordinator ($66,290), High School Teacher ($61,660), Librarian ($59,500), Training and Development Specialist ($61,210), Postsecondary Education Administrator ($95,410)

Media - Public relations specialist ($73,250), Sound engineering technician ($67,360), Graphic designer ($59,970), Writer ($81,120), Market Research Analyst ($63,790), Advertising Sales Agent ($53,310), Advertising, Promotions, and Marketing Managers ($135,900), Sales Manager ($126,640)

Career Choices*

Please select the top three categories in which your child has an interest.

Health Care

Agriculture, Food, and Natural Resources

Architecture and Construction

Arts, Audio/Video Technology, and Communication

Business and Finance

Education and Training

Media

STUDENT CONSENT RELEASE

I now grant Environmental Leaders of Color, their successors, and their assignees the right to record the image and voice and use the artwork or written work of my child, on videotape, on film, on photographs, in digital media and any other form of the electronic or print medium and to edit such recording at their discretion.

I understand that my child’s full name, address, and biographical information will not be public. I further grant Environmental Leaders of Color, their successors, and assignees the right to use and allow others to use my child’s image or voice on the internet, in brochures, and any other medium and now consent to such use.

I now release Environmental Leaders of Color, their successors, and their assignees and any using my child’s image or voice, artwork, or written work according to this media release from any claims, damages, liabilities, costs, and expenses which my child or I now have or may hereafter have because of any use thereof.

I agree that the recorded image and voice and my child's artwork and written work belong to Environmental Leaders of Color and that my child or I will not get monetary compensation.

I understand that the provisions of this release are legally binding. Please check one:*

I consent

I do not consent

STUDENT TRIP PERMISSION

# To enhance the learning experience, ELOC will take children to points of interest.
# All field trips will be organized through and with your child’s participating summer program host site.
# Children will only participate in field or class trips if a signed Field Trip Permission form is on record.
# Children will be accompanied by an adult(s) on field trips, except when the child will travel to a pickup point with the parent's consent.
# Children with food allergies must bring their lunch or snacks. The organizer will not provide food or snacks to children with food sensitivities or allergies and will prohibit their participation if they do not bring lunch or snacks.

Child’s Allergies (Please mention if any)

If emergency medical treatment is necessary, I give the activity leader(s) the right to transport and authorize medical treatment on behalf of the child. The parent/Guardian understands that the activity leader(s), or designee, will make every event reach them before authorizing any medical treatment.

My child’s physician is*

(Name, City, and Telephone Number of Child’s Physician)

Two emergency contacts*

(List the Names and Telephone Numbers of the Emergency Contacts)

I covenant and agree to release and hold harmless the Environmental Leaders of Color, its officers, directors, agents, and representatives associated with the event from and against all liability, loss, damages, claims, or actions (including costs and attorneys fees) for bodily injury and property damage, to the extent permissible by law, arising out of participation in this field trip.*

I consent

I disapprove (My child will be unable to participate in field/class trips)

Consent*

I here by declare that all the information provided by me in this form are correct to the best of my knowledge, and I agree to the pricy policy of the Environmental Leaders of Color*

Parent/Legal Guardian Signature*