2016-2017 Campus Collaborative Breakout Trip Leader Application

Thanks for your interest to be a Breakout Princeton leader!

To apply, all leaders must complete and submit this form.

LEADER TRAINING REQUIRED

Before completing the applications, please review the Pace Center Breakout Website and Trip Leader Requirements.

Breakout Princeton is accepting applications for Trip leaders for a Campus Collaborative Breakout trip with the Carl A. Fields Center for Equality and Cultural Understanding. This trip will depart during Spring Breakout 2017. The trip focus is on pipeline of education for students of color.

If you have any questions or concerns please contact Pace Center Program Coordinator and Breakout Staff Advisor, Eliza Blades, via email at eblades@princeton.edu or by phone at 609.258.9746.

Suggestion: Complete your answers to these questions in a separate document before submitting, then cut and paste into this form to avoid losing your answers.

Check the box below to confirm that you have read and understood the Trip Leader Requirments. *

I have read the Breakout Trip Leader Guidelines.

Part 1: BASIC INFORMATION

Full Legal First Name *

Full Legal Last Name *

Preferred/Nickname

Class Year *

PU ID: *

Princeton Email Address *

Phone Number: *

Date of birth: *

GPA: *

Gender Pronouns:

Major (if known)

Certificate(s)

Are you van-certified by Princeton? *

Yes

Approximately when did you last take Princeton's road test?

If not, are you willing to drive for a Breakout trip? *

Yes

Name of person who could serve as a reference (e.g. employer, faculty, Princeton administrator):

Reference relationship to you:

Reference email:

Reference phone:

How did you hear about Breakout Princeton?

Part 2: LEADERSHIP INFORMATION
Please limit your responses to 200 words.

1. Why do you want to be a Breakout Trip Leader? What personal and professional goals do you have for this leadership role? *

2. What does service mean to you? Please describe your most meaningful service experience. *

3. What does the relationship between a Breakout Trip and the community look like to you? *

4. How would you plan your trip to relfect a diversity of veiws and perspectives? *

5. Give an example of a challenging time when you had to lead your peers. What did you learn about yourself and the skills necessary to lead? *

6. Are there any parts of your identity/experience that you would like to share with the selection committee that you think would uniquely qualify you to lead this trip well? *

7. List your anticipated major activities for the semester and the expected time commitment of each (total credit hours, sports, jobs, other programs or organizations, etc.). How much time each week per semester, will you devote to organizing your Breakout trip? *

8. If we were to ask your peers and professors to name 3 strengths and 3 challenges of yours, what would they say? *

Students on disciplinary probation at the time of their application are not eligible to participate in the Breakout program. Pace Center staff is only able to verify your eligibility with your consent noted by the waiver below. Please read the waiver and indicate your consent. Note that any information related to disciplinary records will be shared only with University staff.

In submitting this application, I permit the Pace Center for Civic Engagement to inquire about my student disciplinary records at Princeton, and I permit the Office of the Dean of Undergraduate Students (ODUS) to release such records to the Pace Center. Information from other offices at Princeton, e.g. residential colleges or others, may be requested as part of the application review process to ensure that all students can have a safe and productive experience. I understand that decisions on individual applications are made by the Pace Center on a case-by-case basis and that any information received by the Pace Center will not be released to other students or any third parties. *

Yes, I consent to the above.

No, I do not consent to the above.