La Salle College High School
Philadelphia Urban Immersion Application
June 5- 10, 2011
Urban Immersion Overview
La Salle has had a long legacy of making a difference in the City of Philadelphia. The Urban Immersion is
a unique opportunity for students to live in community and work at various social service organizations in
the city. Students will encounter the poor in soup kitchens, schools, churches, or on the streets. The
project will be based on the principles of the Lasallian Service Corp which are faith, service, and
community.
Students and chaperones will be housed at the Saint Peter Claver Center at 12th and Lombard in Center
City Philadelphia. The Saint Peter Claver Center is sponsored by the Archdiocese of
Philadelphia. Throughout the week, students will work at various service sites that in the city. In
addition, spiritual, educational, and recreational activities will be provided.
For more information, visit http://www.lschs.org/summerservice
*** due in Campus Ministry no later than Wednesday, December 8, 2010 ***
Contact Information
Name _______________________________________________ HR____________
Address
______________________________________________________________________________
______________________________________________________________________________
Phone ______________________________________________________________
Email _______________________________________________________________
Extracurricular Activities (Please list any involvement both at La Salle and outside of school
with ant jobs, sports teams, clubs, etc…)
Community Service Experience (Please list any involvement at La Salle and outside of school)
Essay (Please answer the following in the space provided or on an additional sheet of paper)
Why do you want to participate in a summer service immersion trip? What do you hope to gain
from this experience? What do you hope to contribute?
LA SALLE COLLEGE HIGH SCHOOL SUMMER SERVICE PROGRAM
MEDICAL INFORMATION & LIABILITY RELEASE
Please print and complete all areas.
Name _________________________________________________ Birth Date ____________________
First Initial Last
Address ______________________________________________________________________________
Street City State Zip
Home Phone _______________________________ Cell Phone______________________________
EMERGENCY TELEPHONE NUMBERS:
Phone numbers where our youth ministry leader can reach a parent or an emergency contact for the child
named above during scheduled events.
Parent/Legal Guardian: Cell ___________________________ Work ________________________
Emergency Contact: Name __________________________ Phone _______________________
MEDICAL INSURANCE CARRIER:
Parent/Guardian’s Insurance Group Name _________________________________________________
Insurance Group Number________________________________________________________________
MEDICAL INFORMATION:
o Family physician’s Name _____________________________Phone_______________________
o Date of last tetanus shot: __________________________________________________________
o Allergies, conditions, dietary restriction, special needs, medical concerns of which we should be
aware:
Food ___________________________________ Drug _____________________________
Animal _________________________________ Other______________________________
o Limitations of which we should be aware: ___________________________________________
o My child requires the following medicine: ______________________ Frequency ___________
o Please List ALL Medications that your son will have in his possession
o My child has permission to be given Tylenol or Ibuprofen if they request it.
Yes No
In case of Medical Emergency I understand that, in the event medical treatment is required, every effort
will be made to contact me or the emergency contact person. However, if I cannot be reached, I give
permission to the staff to secure the services of a licensed physician to provide the care necessary,
including hospitalization, anesthesia, injection, or surgery for my child’s well-being. I hereby agree to
indemnify and hold harmless LaSalle College High School and its officers, employees, and volunteer staff
from any liability.
Date ____________________
Signature of Parent or Legal Guardian
Permission Form
Applicants Name ____________________________________________________________
______________________________________ has my permission to apply for the Philadelphia
Urban Immersion trip sponsored by La Salle College High School. I understand that a $300.00
participation fee is required as part of this application. There will be no additional fundraising
for the Urban Immersion. If he is not selected, the $300.00 will be returned immediately.
If selected, the participation feel will be non-refundable since it will be used to secure housing.
Also, he will be required to attend regular meetings throughout the school year leading up to
the trip.
In addition, he will be required to follow all applicable rules and regulations as stipulated in the
La Salle College High School handbook leading up to and while attending the trip. If there are
any serious infractions while on the trip, I understand that my son may be required to return
home prior to the end of the trip.
Applicant’s Signature _________________________________________________________
Parent’s Signature ___________________________________________________________
Urban Immersion Teacher Recommendation
*** Please return to campus ministry by December 8, 2010
Applicants Name _____________________________________________________________
Dear Faculty/ Staff Member: Please answer the following in the space provided or attach on a
separate sheet. When completed, please return to Campus Ministry.
1.) How long have you known the applicant and in what capacity?
2.) Compared to other students, how would you rate the applicant:
Below
Average
Average
Good
(Above
Average)
Very Good
(Well above
average)
Excellent (top
10%)
Maturity
Leadership Skills
Ability to Work in Group
Work Ethic
3.) Anything else that you feel is important for us to know (would you have any concerns
with taking the student on a trip of this nature)?
Teacher’s Signature _________________________________________________________
Teacher’s Name ____________________________________________________________
