2019 Student Free Speech Summit
Page 1
Student Information
1. Please complete the application below to apply for the 2019 Student Free Speech Summit. For more information on the program, visit
www.billofrightsinstitute.org/engage/students-programs-events
.
2. The red * means that the field is required.
3. Contact
mhoward@mybri.org
if you have any questions.
First Name
Last Name
Personal Email Address
School Email Address
At which email address do you prefer to be contacted?
Personal
School
Street Address
City
State
Please select...
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
U.S. Overseas Military Base
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip Code
If you are living overseas, please indicate your current country of residence.
Phone Number ###-###-####
Gender
Male
Female
When were you born? (MM/DD/YYYY)
To comply with legal requirements, we must ask for your birthdate.
School Information
School Name
High School Graduation Year
Please enter a 4-digit year (example: 2018)
Grade Point Average (on a 4.0 scale)
School City
School State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
U.S. Overseas Military Base
School Type
Public
Private
Parochial
Charter
Alternative
Homeschool
Online
Other
Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Phone Number ###-###-####
Parent/Guardian Email Address
Referring Teacher Information
Please include the contact information for a social studies teacher (history, government, civics, economics, etc.). We may contact this teacher to provide a reference for you.
Teacher First and Last Name
Teacher Phone Number ###-###-####
Teacher Email Address
Page 2
More Information About You
What sources do you use to get news? (You may select multiple options)
CNN
FOX News
MSNBC
CBS
NBC
ABC
Wall Street Journal
The Economist
Yahoo
Google
Huffington Post
Drudge Report
The Daily Show
New York Times
Local Newspaper
Other
If you chose "other" under news sources, please explain:
Which (if any) of the following groups or activities have you been involved in since you started high school? (You may select multiple options)
Athletics
Boy/Girl Scouts
Boys/Girls State
DECA
FBLA
HOBY Youth Leadership
Interact Club
Key Club
Mock Trail
Model United Nations
National Honor Society
ROTC
School Government
School Newspaper
School Yearbook
Speech/Debate
We The People
YMCA Youth and Government
Other
None
If you chose "other" or "Athletics" under groups and activities, please explain:
In which (if any) of these groups have you held a leadership position? (You may select multiple options)
Athletics
Boy/Girl Scouts
Boys/Girls State
DECA
FBLA
HOBY Youth Leadership
Interact Club
Key Club
Mock Trial
Model United Nations
National Honor Society
ROTC
School Government
School Newspaper
School Yearbook
Speech/Debate
We the People
YMCA Youth and Government
Other
None
Please explain the extent of your leadership positions chosen:
Have you taken Advanced Placement (AP) or Dual-Credit courses in any of the following? (You may select multiple options)
U.S. History
World History
U.S. Government and Politics
Comparative Government and Politics
Microeconomics
Macroeconomics
Philosophy
Other
IB Program
How did you hear about the Student Free Speech Summit?
Please select...
Bill of Rights Institute Website
Bill of Rights Institute Email
Facebook
Twitter
Instagram
Pinterest
Search Engine
Another Organization
Friend/Colleague
Direct Mail/Postcard
Guidance Counselor
Teacher
Parent/Family Member
Scholarship Website
Scholarship Email
If you searched the internet, which search engine did you use?
If you were referred by an another organization, which organization told you about the Bill of Rights Institute?
Page 3
Essay Questions
Please answer the following questions. We recommend that you type your responses in another program and then copy and paste each essay in the appropriate text box so that the page does not time out.
In 200 words or less, explain why you want to participate in the 2019 Student Free Speech Summit and how will being a participant will affect your career goals?
In 200 words or less, please explain why you believe free speech is an important right in the United States?
In 200 words or less, please describe one political issue that you are passionate about. Why are you passionate about it? Why should that issue be a primary concern for legislators? In your opinion, what avenues could be taken to address the issue?
Tell us when you want to hear from us
Knowledge is power. Our
student newsletters feature internships, jobs, scholarship opportunities, social media contests, current events, and other exciting student focused opportunities that you won't want to miss! Should we sign you up?.
Yes
No
By filling out this application you acknowledge that you have received a copy of, and agree to, the Bill of Rights Institute's Privacy Policy. To read over the Institute's privacy policy, please visit the following URL: https://www.billofrightsinstitute.org/about-us/institute/privacy-policy/
Yes
PARTICIPANT PUBLICITY RELEASE
I, the undersigned, in consideration of possible publicity and other valuable consideration, receipt of which is hereby acknowledged, hereby authorize The Bill of Rights Institute and its affiliates, designees, assignees, transferees, licensees, grantees and any entities or persons acting on behalf of any of the foregoing (collectively, “Grantees”) to film, photograph and otherwise record my likeness, voice and any other form of my identity, and grant Grantees the right to create, reproduce, alter, modify, publish, display, sell, transfer, exhibit and use my voice, likeness, and any other form of my identity in any manner (including without limitation advertising, promotion, and merchandising) or form, including without limitation all video, audio, digital, and print formats and any other media now known or hereafter created, including without limitation use via computer, the Internet, films, DVDs, video tapes, audio tapes, digital audio files, digital image files, photographs, prints, copies, facsimiles and electronically captured images thereof, without limitation as to method of reproduction or exhibit and without any territorial or time restrictions.
Further, I hereby relinquish, give, transfer, and assign to Grantees all right, title, copyright and interest I may have in the finished product contemplated by this Release, agree that any and all materials created by or on behalf of Grantees are the property of Grantees, and I waive any right of review or inspection. I agree that no other material needs to be submitted to me for any further approval, and Grantees shall be without liability to me or any person for any distortion or illusionary effect resulting from the publication or dissemination of any likeness, audio recording, or other indicia of my identity.
I state further that: (a) I am of legal age and capacity; (b) I acknowledge that nothing herein requires Grantee(s) to use my likeness as described herein or elsewhere; (c) I acknowledge that no compensation or consideration will be provided to me for the rights and releases granted herein, other than the potential publicity; (d) I have read, or have had read to me, this Release and have had the opportunity to ask questions before its execution, and I am fully familiar with and understand its contents; and (e) I hereby irrevocably release Grantees from any and all liability based upon, arising out of or in any way related to this Release or the exercise of the rights granted herein.
I have read this statement and agree to it
Acceptances are made on a rolling basis, with the final acceptances made by June 1st, 2018.
Thank you for your application, we look forward to reviewing your application!
Contact Information