APPLICATION FORMS ARE DUE JANUARY 8, 2010

WHAT: The Pilipino Youth Conference (PYC) is a three-day event filled with workshops,
organizational and leadership development activities, social activities, college information,
and cultural and artistic empowerment to encourage youth to pursue higher education.

MISSION: The PYC Retreat is used to help high school students open their minds,
discover their potential, and become empowered through learning about their heritage,
cultural identity, and potential power in society. The purpose of the retreat is to give students
information dealing with personal issues (such as identity, sexuality, leadership, and
activism), social issues (such as womyn history and immigrant experiences), and tips to
receive higher education through college. The retreat will be focused on issues related to
and facing today’s Filipino-American youth. However, you do not have to be Filipino to attend!

WHO: BRIDGE of UC Davis will be hosting this year’s retreat. BRIDGE is a Filipino based
outreach and retention program. We focus on higher education and activism for high school
and college students. Any high school student is welcome to attend and those interested in
activism, higher education, and Filipino/a culture. You DO NOT need to be Filipino to
attend!!

WHEN: Friday, January 22 through Sunday, January 24, 2010. (Yes, it will be overnight!)
Students will be staying overnight, and chaperoned hotel accommodations will be provided.

WHERE: UC Davis

HOW: Fill out the attached application and fax/mail to Nicole Tomboc (info is on application)
by January 8, 2010. Since this is on a first come first serve basis, we will notify you of your
participation in the retreat. Once accepted, you must bring $25 registration fee on January
22 (fee waivers available, if necessary).

FOR MORE INFO:

Coordinator: Nicole Tomboc
Email: pycretreat2010@gmail.com
Phone: (408) 219-1770

To submit application, E-MAIL to pycretreat2010@gmail.com,

FAX to (530) 752-3257 (ATTN: Nicole Tomboc),
MAIL TO Nicole Tomboc 813 Zaragoza Street, Davis, CA 95616, or
If you are a member of PYC, applications may be given to your PYC Advisor.
APPLICATION FORMS ARE DUE JANUARY 8, 2010.
 APPLICATION FORMS ARE DUE JANUARY 8, 2010

High School Student Registration Form

First Name:       Last Name:      
Birth Date:      
Gender: M F Decline to State
T-Shirt Size: Small (S) Medium (M) Large (L) X-Large (XL)
Street Address:      
City:       State:       ZIP Code:      
Home Phone:       Cell Phone:      
E-Mail Address:      
School Name:       School Phone #:      
School Address:      
City:       State:       ZIP Code:      

Please rate your interest in the following (1 being of highest interest, 5 being of least interest):
Poetry:      
Music:      
Modern Dance:      
Cultural Dance:      
Visual Arts:      

If you register and we confirm your spot, we expect you to arrive on January 22, 2010 and participate all
three days of social, personal, and culturally empowering activities that will end on January 24, 2010. Your
signature commits you to the three-day retreat once your registration is confirmed. You are NOT allowed to
leave at anytime during entire period of the retreat.

IMPORTANT: If you submit your application via e-mail, you MUST bring a
form WITH all required signatures on the day of the retreat.

______________________________________ _______________________
Student Signature Date

To submit application, E-MAIL to pycretreat2010@gmail.com,

FAX to (530) 752-3257 (ATTN: Nicole Tomboc),
MAIL TO Nicole Tomboc 813 Zaragoza Street, Davis, CA 95616, or
If you are a member of PYC, applications may be given to your PYC Advisor.
APPLICATION FORMS ARE DUE JANUARY 8, 2010.
 APPLICATION FORMS ARE DUE JANUARY 8, 2010

High School Student Information / Emergency Form

Full Name:       Birth Date:      
Gender: Male Female Decline to State
Street Address:       City:       State:       ZIP Code:      
Name of Parent/Guardian:       Relationship:      
Home Phone:       Cell Phone:       Work Phone:      

Please answer the following questions:

Do you have any existing medical conditions? If yes, please explain.
     
Please describe any medication(s) and dosage that we should know of in the event of an emergency.
     
Do you have any disabilities we should be aware of? If so, please explain.
     
Please explain any other special instructions that we should be aware of in regards to your stay with us:
     
Do you have any dietary considerations? If so what?
     

Are you covered by health/life insurance? Y N

If so, what type?       Policy#:      

In the event of an emergency, whom, besides your parent/guardian should we contact?

Name:       Relationship:       Phone:      

Attention Parents: In the event of an emergency, should your child require medical attention, do you give your permission
for those in charge to seek the necessary medical attention? If so, please sign below.

IMPORTANT: If you submit your application via e-mail, you MUST bring a
form WITH all required signatures on the day of the retreat.

_______________________________________ ________________________
Parent Signature Date

To submit application, E-MAIL to pycretreat2010@gmail.com,

FAX to (530) 752-3257 (ATTN: Nicole Tomboc),
MAIL TO Nicole Tomboc 813 Zaragoza Street, Davis, CA 95616, or
If you are a member of PYC, applications may be given to your PYC Advisor.
APPLICATION FORMS ARE DUE JANUARY 8, 2010.
 APPLICATION FORMS ARE DUE JANUARY 8, 2010

High School Student Participation

Terms & Conditions Contract

In order for the Pilipino Youth Coalition Retreat to be a fun and learning experience for both you, the high school
student, we need your full cooperation and commitment. We ask that you read carefully the following terms and
conditions before you commit to the three-day event, which will be held from January 22-24, 2010. If you
register, and we reserve you a spot, we expect you to arrive on the 22rd and participate for the full three days
and agree to the following:

1. I will behave in a cooperative and considerate manner while I am a participant of the Pilipino Youth
Coalition Retreat.
2. I will be a respectful guest in the University Inn chaperoned by the Bridge Coordinators.
3. If I should separate from my host by accident or by choice, I will make sure to contact my host or another
host immediately to inform them of my situation.
4. I will take full financial responsibility for any damages I am found to have incurred during my participation in
the Pilipino Youth Coalition Retreat.

Violation and failure to follow through with these terms and conditions will result in your dismissal from the event
and your parents or guardian will be contacted immediately.

If you are chosen to attend, you will be asked to pay a $25 registration fee
at the retreat on Friday, January 22. Please make checks payable to
“Bridge: Pilipino Outreach and Retention Program”. If you are unable to
pay, please contact Nicole to inquire information on fee waivers.

By signing below, I testify that I have read and understood the above information, terms and conditions and
agree to abide by them while I am a participant of the Pilipino Youth Coalition Retreat from January the 22rd
through the 24th, 2010.

IMPORTANT: If you submit your application via e-mail, you MUST bring a
form WITH all required signatures on the day of the retreat.

_______________________________ _______________________________ ________________

Name (please print) Student Signature Date

_______________________________ _______________________________ ________________

Name of Parent (print) Parent Signature Date

To submit application, E-MAIL to pycretreat2010@gmail.com,

FAX to (530) 752-3257 (ATTN: Nicole Tomboc),
MAIL TO Nicole Tomboc 813 Zaragoza Street, Davis, CA 95616, or
If you are a member of PYC, applications may be given to your PYC Advisor.
APPLICATION FORMS ARE DUE JANUARY 8, 2010.
 APPLICATION FORMS ARE DUE JANUARY 8, 2010

PERSONAL QUESTIONNAIRE... JUST TO GET TO KNOW YOU

(You may attach your answers on a separate page)
1. List your Interests, Hobbies, and Passions.

     

2. Why do you want to participate in this retreat? What do you hope to gain?
     

3. What experience do you have working in the Filipino-American Community (High School, PYC, Family,
etc.)?

     

4. Check which apply to your personality.

Creative Shy
Outgoing Humorous
Sarcastic Passionate
Assertive Talkative
Listener Serious
Reserved Spontaneous
Laid Back OTHER:      

5. If there was one aspect in your life that you want to change, what is it? Why?
     

6. If you could pick a song that represents yourself, what would it be? Why?

     

7. Have you attended PYC Retreat in the past? If so, when?

     

To submit application, E-MAIL to pycretreat2010@gmail.com,

FAX to (530) 752-3257 (ATTN: Nicole Tomboc),
MAIL TO Nicole Tomboc 813 Zaragoza Street, Davis, CA 95616, or
If you are a member of PYC, applications may be given to your PYC Advisor.
APPLICATION FORMS ARE DUE JANUARY 8, 2010.