SESH: Structural Engineering Students for Haiti

Haiti Service Trip Application

APPLICATION NO. NAME: Please detach this cover page and keep for your records. WHAT IS SESH? The STRUCTURAL ENGINEERING STUDENTS FOR HAITI (SESH) is an unaffiliated student-initiated group devoted to the rebuilding efforts in Haiti following the January 2010 earthquake. This service trip will provide a memorable learning experience by exposing social and cultural issues firsthand. The service trip presents a unique opportunity to apply the skills and knowledge learned inside the classroom to a real situation and to positively affect a real community. OUR GOALS SESH is striving to experience and observe the effects of poor structural design in seismic areas while developing holistic views of our education and, ultimately, encouraging initiative and social responsibility as structural engineers. THE APPLICATION Please keep in mind that there are a limited number of spots available. We ask that you put in the required time and effort while completing this application. All responses must be typed in a separate document and attached to this application. Please put your application number in the header and do not include any personal information on this additional document. Applications are due 5/5/2012 by 2:00 PM to Alex Daddow After all applications have been submitted, the panel will review them you will be notified by e-mail in December. Following the application process and in preparation for this trip, you will be required to attend mandatory training sessions, group meetings, and fundraising events. Failure to do so can result in losing your spot on this service trip. We thank you for taking the time to complete this application.

SESH: Structural Engineering Students for Haiti

Haiti Service Trip Application

APPLICATION NO. PERSONAL INFORMATION NAME: DATE OF BIRTH: PASSPORT #: MAJOR / YEAR: EXPIRATION DATE:

CONTACT INFORMATION E-MAIL ADDRESS: PHONE NUMBER: PERMANENT ADDRESS:

SESH: Structural Engineering Students for Haiti ASSOCIATED RISKS DISCLAIMER This trip is NOT affiliated with the California Polytechnic State University, the College of Architecture and Environmental Design, the Architectural Engineering Department, or the Structural Engineers Association of California (SEAOC). I, , hereby acknowledge that I have voluntarily applied to potentially participate in the service trip described in this application. I am aware of certain risks and dangers that may occur during the trip, including, but not limited to: 1. Low availability of resources Food Clean drinking water Adequate shelter 2. Exposure to disease Malaria Dengue Fever Tuberculosis Cholera HIV Leptospirosis Diarrhea 3. Vulnerability to the environment Falling debris Uneven/unpaved roads Dangerous driving Earthquake aftershocks 4. Violent or hostile activity Petty theft Homicide Kidnapping Death

SESH: Structural Engineering Students for Haiti ASSUMPTION OF LIABILITY I acknowledge that I have been informed of the possible risks and hereby agree to be solely responsible for my own personal welfare and assume any and all risks of illness, injury or death. I release and discharge the STRUCTURAL ENGINEERING STUDENTS FOR HAITI (SESH) from all claims or demands for damages resulting from my participation in the trip. I state that I am physically and mentally prepared for the rigors of the trip. I agree to attend all mandatory training sessions, receive and provide documentation of all necessary vaccinations, complete any additional required documents or forms, and follow all rules, regulations, and expectations set forth by SESH, Ken ODell, and the affiliated non-governmental organization that we will be travelling with. I am fully aware that this is a release of liability and sign it on my own free will. I have read it in its entirety and agree to all the stated conditions mentioned within. I recognize that SESH will not be liable to me, directly or indirectly, under any circumstances, for any costs, expenses, losses or damages to person or property, incurred as a result of my actions. Applicant Print Name: Applicant Signature: Date: Witness Print Name: Witness Signature: Date:

SESH: Structural Engineering Students for Haiti DO NOT WRITE ON THIS PAGE.

APPLICATION NO.

Total

SESH: Structural Engineering Students for Haiti COMPLETED COURSEWORK Course ARCE 211 ARCE 212 ARCE 227 ARCE 223/351 ARCE 302/352 ARCE 306/353 ARCE 412 ARCE 483 ARCE 371 ARCE 303 ARCE 304 ARCE 305 ARCE 372 ARCE 451 ARCE 444 ARCE 452

Completed

Currently Taking

Advanced Structural Electives (list in additional document) Please list any other courses that you feel are relevant to this application. PERSONAL STATEMENTS All responses must be typed. 1. Have you travelled outside the U.S.? If so, where and what was the purpose of the trip? 2. How do you hope to grow academically and personally if selected for this trip? 3. How will you contribute to and enhance a group experience? 4. What skill(s) or experience(s) do you have that will help the Haitian community? 5. Describe an experience when you had to adapt to or cope with a sudden change in environment.