Registration for our 18th Urban Leadership Institute (ULI)

Please complete this form to register your child for our Annual ULI Event.

Only complete applications will be accepted.

If you have any questions, please contact us at info@ssmv.org or (315) 733-7768 x 204

Dates: August 17th - 20th and August 24th - 27th, 2026

Times: 9am - 3pm Daily

What is ULI: This is a unique summer opportunity for teens to buld their leadership skills thorugh fun daily acitivities and adenture based learning. This year our theme will be the First Responder Academy. The students will learn about their role in our community, careers in this field, and ways they can support first responders.

WHY ATTEND:

1. To build leadership skills

2. All participants who attend the entire program will receive a certificate that can be used on job applications and college resumes.

WHO CAN ATTEND: Teens attending school. Must be an incoming 9th grader or graduating 12th grader as of the 2025-2026 school year. Students are expected to attend everyday. If they cannot please let us know.

LOCATION: To Be Determined but it will be held in Utica, NY. Students will meet at the same location each day.

DATES: The program will take place for 2 weeks Monday - Thursday each week.

August 17th - 20th and August 24th - 27th

TIME: 9am - 3pm daily

TRANSPORTATON: student will meet at a central location everyday and transportation will be provided to other sites for daily activities.

NOTE:

1. Utica Residents ONLY: Bus pick up from and to home will be provided for free to all students living in Utica. Students must be ready for pick at desiganted time.

2. Rome City School District students: The school district will provide bussing to the Utica program site daily. Pick-up and drop off each day will be at various locations. More details to come.

COST: All students accepted into the program will receive a full scholarship making the program FREE! Lunch and snacks will be provided.

PLUS - if you live in Oneida County students can apply for a work scholarship and be paid to attend! Contact us at info@ssmv.org for more information.

Child's Full Name

First NameLast Name

Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Child's Grade starting the 2026-2027 school year.

Child's Age

School District your child currently attends

Parent/Guardian Full Name

First NameLast Name

Parent/Guardian Address if different from student address listed above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Email Address

example@example.com

Parent/Guardian Preferred Method of Communication for Updates

Child Dietary Restrictions or Allergies - please list all

Does your child have any special needs (physical and medical) that our staff should be aware of - please list all

#1 Emergency Contact Name

First NameLast Name

#1 Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

#2 Emergency Contact Name

First NameLast Name

#2 Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Utica Residents ONLY - does your child need transportation to and from home each day of Program

If you entered yes or maybe, once bussing details are confirmed we will contact you directly with more information.

Utica Residents ONLY - if you child will need transportation to and from home each day please add the address if different from your child's address listed above.

T-Shirt Size

By signing this form I agree to the following:

1. My child will participate everyday from 9am - 3pm (Aug 17th - 20th and Aug 24th - Aug 27th

2. I give consent for my child to take part in trips away from the main location using the bus transporation provided.

3. In case of accident/injury I authorize the program staff to seek all necessary medical, dental, surgical care and/or hospitalization for my child.

4. I give consent for my child to appear in pictures of the activities/events that occur and release those images for publication and use by Safe Schools Mohawk Valley.

5. I have provided information on my child's special needs, allegeries, and dietary restrictions on this form.

6. I understand that Safe Schools Mohawk Valley will not distribute or give any medication, both over the counter and prescbribed.

Signature

Date

Registration for our 18th Urban Leadership Institute (ULI)

Agreements