2020 LDZ Application: Section 1: Student Participant Information (Please Print)

FOR ADMISSIONS OFFICE USE ONLY APPLICATION REQUIREMENTS
RD ____/____/____ ED ____/____/____ 1. $20 application fee (non-refundable)

(Payable to NHI)
AMT ______ DATE ___________ SPR ______
2. Report card (most recent
PM _____ CK _____ RD _____
2020 LDZ Application

[* Required Fields]
Updated: August 19, 2019
SECTION 1: STUDENT PARTICIPANT INFORMATION (PLEASE PRINT)
*Full Name: ____________________________________________________________________ ______________________________

First Middle Last *Home Phone
*Address ____________________________________________________________________ ______________________________

Street Address Apt. *Cell Phone
____________________________________________________________________ ______________________________
City State Zip Code Country *Date of Birth (MM/DD/YYYY)
*Email: ____________________________________________________________________
(Please print clearly to ensure an accurate email) S M L XL XXL
T-Shirt Size (circle one)
*For housing purposes, please select: Male Female
Do you have any special housing requests? (ex. wheelchair accessible, etc.) If yes, please specify _________________________________.
*Have you participated in NHI programs before? Yes No If yes, please list program and year: _____________________________
Optional Data Questions: This information is shared with NHI's College Register partner institutions as asked by the College Board
for college admissions and scholarship purposes. This information is not required for admission to NHI programs.
Are you Hispanic/Latino/a/x? Yes No Prefer Not To Answer
If yes, what best describes your background? Central America Cuba México Puerto Rico South America
Spain Other ______________________ Prefer Not To Answer
If no, what is your race/ethnicity? American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White Prefer Not To Answer
SECTION 2: PROGRAM INFORMATION (SELECT ONE)
⬚ Colorado LDZ ⬚ California LDZ ⬚ National LDZ

June 21-28, 2020 July 12-19, 2020 June 28-July 5, 2020
Colorado State University-Fort Collins University of San Diego Elmhurst College
Fort Collins, Colorado San Diego, California Elmhurst, IL (Chicago)
⬚ East Coast LDZ** ⬚ LDZ Las Americas** ⬚ Texas LDZ

July 12-19, 2020 July 12-19, 2020 July 26 - August 2, 2020
St. Mary’s College Maryland Ciudad de Saber / City of Knowledge St. Mary’s University
St. Mary’s, Maryland (Saturday D.C. Trip) Panama City, Panama San Antonio, Texas
** Bilingual program: Spoken English or Spanish as a second language is strongly advised. English-only speakers and Spanish-only speakers may
experience difficulties at these two programs. We strongly encourage English speakers to have at least two years of study in Spanish as a second
language during middle school or high school for programs in Latin America. For Spanish speakers, we strongly encourage fluency in English or two
years of middle school/high school English to attend programs in the United States.
SECTION 3: SCHOOL INFORMATION (PLEASE PRINT)
*School: ______________________________________ *Graduation Year: ____________ *GPA: ___________
*District: ______________________________________
*Counselor Name: ______________________________________ *Counselor Email: ________________________________________
Principal Name: ______________________________________ Principal Email: ________________________________________
SECTION 4: PARENT/GUARDIAN INFORMATION (PLEASE PRINT)
*Primary Contact: _________________________________________ *Cell Phone: _____________________________________
Occupation: _________________________________________ *Work Phone: _____________________________________
*Email: _________________________________________ *Relationship: Mother Father Family Member Guardian
*Primary email for all NHI email communications & NHI Online Account: ______________________________________________________
(Please print clearly to ensure an accurate email)
Secondary Contact: _________________________________________ Cell Phone: _____________________________________
Occupation: _________________________________________ Work Phone: _____________________________________
Email: _________________________________________ Relationship: Mother Father Family Member Guardian
As the authorizing parent/guardian, I certify that the information contained in this application is true and correct. I understand that NHI
programs are fully supervised and that the cost of the program DOES NOT INCLUDE transportation to and from the campus; unless this is
explicitly communicated. I also understand that all charges, payments, and tuition are NOT REFUNDABLE OR TRANSFERABLE if the
applicant cannot attend.
I acknowledge that in case my child cannot attend the program, the $20 application fee and the $150 deposit are NOT
REFUNDABLE. __________ (initials).
*Signature of authorizing parent/guardian: __________________________________________ Date: _________________________
*Name of authorizing parent/guardian: __________________________________________
SECTION 5: RECRUITED BY (IF APPLICABLE)
NOTE: If the applicant was recruited by a current or former NHI member, please add the name below. This supports the recruiter to be
eligible for local and/or summer staffing opportunities at NHI programs.
Name: ___________________________________________ Previous NHI Program: ___________________________________

(include site & date)
Email: ___________________________________________
SECTION 6: DOCUMENTS
⬚ Completed application with signature

⬚ $20 USD application fee (can be cash, check or
money order)
Mailing Address Shipping Address (FedEx/UPS/DHL)
National Hispanic Institute
⬚ Most recent report card National Hispanic Institute
P.O. Box 220 472 FM 1966
Maxwell, Texas 78656 USA FOR QUESTIONS OR MORE INFORMATION, PLEASE CONTACT: Maxwell, Texas 78656 USA
512-357-6137 / 512-357-2206 [fax] 512-357-6137 / 512-357-2206 [fax]
[email protected]
www.nationalhispanicinstitute.org

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FOR ADMISSIONS OFFICE USE ONLY APPLICATION REQUIREMENTS

RD ____/____/____ ED ____/____/____ 1. $20 application fee (non-refundable)

2020 LDZ Application

SECTION 1: STUDENT PARTICIPANT INFORMATION (PLEASE PRINT)

*Full Name: ____________________________________________________________________ ______________________________

*Address ____________________________________________________________________ ______________________________

*For housing purposes, please select: Male Female

Are you Hispanic/Latino/a/x? Yes No Prefer Not To Answer

Spain Other ______________________ Prefer Not To Answer

Native Hawaiian or Other Pacific Islander White Prefer Not To Answer

SECTION 2: PROGRAM INFORMATION (SELECT ONE)

⬚ Colorado LDZ ⬚ California LDZ ⬚ National LDZ

⬚ East Coast LDZ** ⬚ LDZ Las Americas** ⬚ Texas LDZ

*School: ______________________________________ *Graduation Year: ____________ *GPA: ___________

*Counselor Name: ______________________________________ *Counselor Email: ________________________________________

Principal Name: ______________________________________ Principal Email: ________________________________________

SECTION 4: PARENT/GUARDIAN INFORMATION (PLEASE PRINT)

*Primary Contact: _________________________________________ *Cell Phone: _____________________________________

Occupation: _________________________________________ *Work Phone: _____________________________________

*Email: _________________________________________ *Relationship: Mother Father Family Member Guardian

Secondary Contact: _________________________________________ Cell Phone: _____________________________________

Occupation: _________________________________________ Work Phone: _____________________________________

Email: _________________________________________ Relationship: Mother Father Family Member Guardian

*Signature of authorizing parent/guardian: __________________________________________ Date: _________________________

*Name of authorizing parent/guardian: __________________________________________

SECTION 5: RECRUITED BY (IF APPLICABLE)

Name: ___________________________________________ Previous NHI Program: ___________________________________

⬚ Completed application with signature

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RD // ED // 1. $20 application fee (non-refundable)

*Full Name: ______________________________________

*Address ______________________________________

⬚ East Coast LDZ ⬚ LDZ Las Americas ⬚ Texas LDZ

School: ____________________________ Graduation Year: *GPA: _

Counselor Name: Counselor Email: __

Principal Name: Principal Email: __

Primary Contact: _____ Cell Phone: _

Occupation: _____ *Work Phone: _

Email: _________________________________________ Relationship: Mother Father Family Member Guardian

Secondary Contact: _____ Cell Phone: _

Occupation: _____ Work Phone: _

*Signature of authorizing parent/guardian: __________________ Date: _

Name: _________ Previous NHI Program: _