ACM Student Leadership Summit: Student Appointment Confirmation and Registration Form (to be completed by student) Step 1 of 5 20% Congratulations on your appointment to the ACM Student Leadership Summit! In addition to the in-person Summit on March 31 and April 1 in Chicago and the online Cultural Intelligence Accelerator (CQA), you will be required to participate in two virtual meetings: an initial meeting on March 8 from 8:00 – 9:00 p.m. Central and a pre-departure meeting on March 27 from 8:00 – 9:00 p.m. Central. Please complete the following form to assist ACM and Common Purpose in preparing for the Summit. Please confirm your participation in the Summit by completing and submitting this registration form no later than February 23. Name(Required) First Last Your College/University Email(Required) Your Personal Email(Required) Your Mobile Phone Number(Required)Home City(Required) We collect this information so that we can better understand the reach of this program.Home State/Province(Required) We collect this information so that we can better understand the reach of this program.Home Country(Required) We collect this information so that we can better understand the reach of this program.Gender(Required) Female Male Non-binary Other We collect this information for lodging purposes.Pronouns(Required) College(Required)Beloit CollegeCarleton CollegeCoe CollegeColorado CollegeCornell CollegeGrinnell CollegeKnox CollegeLake Forest CollegeLawrence UniversityLuther CollegeMacalester CollegeMonmouth CollegeRipon CollegeSt. Olaf CollegeExpected month and year of graduation(Required) Academic Major(s)(Required) Academic Minor(s) Are there any particular careers/industries you are currently exploring?(Required)Background(Required)Please provide a brief overview of your leadership experience, what you wish to gain through your participation in the Summit, and any other information that you believe would be helpful to ACM and Common Purpose in preparing for the program.Skills & Mindsets you would like to develop(Required) Agility Collaboration Communication Creativity Cultural Intelligence Disruption Empathy Entrepreneurial mindset Growth mindset Inclusivity Influence Innovator mindset Inspiring trust Leadership Networking Problem solving Resilience Self-awareness Self-confidence Teamwork Other If you checked the box for "other" above, please explain. Would you like to opt into a gender-neutral lodging assignment?(Required) Yes No Other A gender-neutral lodging assignment refers to a lodging option in which students mutually agree to share a multiple-occupancy bedroom without regard to the gender identity of the occupants. If you have questions or would like to discuss this option further, please contact mvertovec@acm.edu.Dietary Restrictions or Food Allergies Will you need any reasonable accommodations to participate in the ACM Student Leadership Summit?We aim to make this program accessible to all, including for those who have a disability or face significant challenges due to health, well-being or personal circumstances.Emergency Contact Name(Required) First Last Emergency Contact Relationship(Required) Emergency Contact Phone Number(Required)Emergency Contact Email(Required) Data Protection: Use of Your DataIf you choose to participate in the ACM Student Leadership Summit, ACM and Common Purpose may store and use your data to send you information related to the program and to request feedback. ACM and Common Purpose are data controllers for the purposes of the EU General Data Protection Regulation (GDPR) 2018. Except in connection with the activities described above or where required to do so by law, ACM and Common Purpose will not disclose your data to third parties without your consent. ACM and Common Purpose take all reasonable precautions to prevent the loss, misuse or alteration of your data. To review Common Purpose's full Privacy and Data Protection Policy, please visit http://commonpurpose.org/privacy-data-protection-policy. If you have questions about the use of your data, please email mvertovec@acm.edu or info@commonpurpose.org.During the ProgramIf you choose to participate in the ACM Student Leadership Summit, we may publish your name and college strictly to members of your own participant group as part of any materials distributed to fellow participants.After the ProgramSuccessfully completing a Common Purpose program means you become an alumnus and will automatically receive Common Purpose's alumni newsletter. The Common Purpose Alumni team may send you occasional email updates, including the Common Purpose quarterly newsletter.I am happy for Common Purpose to send me alumni communications.(Required) Yes, I opt in. No, I opt out. Media ReleasePlease review the following instructions for both Common Purpose and ACM.Common Purpose Media ReleaseCommon Purpose may take photographs and videos during this program to be used for commercial, knowledge sharing, and evaluation purposes. If you would prefer not to be included in these, please notify a Common Purpose staff member during the program or via email at marketing@commonpurpose.org.Associated Colleges of the Midwest (ACM) Media ReleaseThank you for your participation in an ACM-related activity. On occasion, representatives from the ACM may wish to photograph, record video and/or audio, and/or interview those connected with our organization. As a nonprofit educational consortium, our goal is to highlight and showcase the work we are doing via our website, videos, emails, posters, brochures, social media, and other marketing materials. As a participant in an ACM activity, your likeness may be captured in photos, videos, or other mediums during the activity. Photos are typically posted directly to the ACM website and/or social media platforms and may also be used in publications such as brochures, flyers, and annual reports. Video content is typically posted on the ACM YouTube channel and embedded into the ACM website. Video content may or may not include captions or written transcriptions. Please complete the waiver below to confirm whether or not you give ACM your permission to use your name and likeness for the purposes described above. While our goal is to post as much web content as possible related to ACM activities, we also respect your right to privacy. Thank you for your cooperation and support. If you have any questions, please contact mvertovec@acm.edu.I give the Associated Colleges of the Midwest (ACM) irrevocable right to use my name and likeness in any photograph, video, audio recording, or other medium in which I appear and for any lawful purpose, including illustration, promotion, advertising, or web content. I understand that these mediums may be edited, copied, exhibited, published, or distributed, and I waive the right to inspect or approve the finished product, including written material that may be created in connection therewith. I also waive any rights of compensation or ownership thereto. It is understood that my participation in these photographs and recordings is done of my own free will. By signing this form, I acknowledge that I have read and fully understand this release, and agree to be bound thereby. I hereby release ACM from any and all claims or liability arising from, or in connection with, ACM’s use of my likeness in these images or recordings.(Required) a. Yes, I agree to the above statement. b. I agree to the above statement but with the exception of the following (please specify below): c. No, I do not agree to the above statement. If you answered "b" to the question above, please explain your answer here. Common Purpose Terms and ConditionsPlease review Common Purpose's terms and conditions: https://commonpurpose.org/common-purpose-terms-and-conditions/. Please note that there is no fee for the ACM Student Leadership Summit.I have read and agree to Common Purpose's terms and conditions. I confirm by electronically signing and submitting this registration form that I have read and understand the terms and conditions. I understand that I have a commitment to participate in all required components of the ACM Student Leadership Summit and that failure to do so may jeopardize my ability to complete the program.(Required) I agree with this statement. I do not agree with this statement. Electronic Signature and Form SubmissionBy completing this registration form with your electronic signature below, you agree to all terms outlined in this form. You also agree to your participation in the ACM Student Leadership Summit as outlined in the call for student appointments and by all terms described in this registration form. Additionally, you agree that the personal data provided by you and the staff member who appointed you will be utilized by ACM and Common Purpose in order to register you for the program and manage and deliver the program only.Full Name(Required) Date(Required) MM slash DD slash YYYY Electronic Signature Agreement(Required) I accept. I do not accept. By selecting the "I accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. Δ
