STEM Club Leadership Training Summer Camp
Student Application Form
STUDENT’S NAME________________________________________________________
first
middle
last
ADDRESS______________________________________________________________
street address or PO box
city
zip code
CONTACT INFORMATION___________________________________________________
home phone
cell phone
email address
CURRENT SCHOOL__________________________________________________________________
GRADE (16-17 ACADEMIC YEAR)_______________________ GPA_________________________
mm/dd/yy
DATE OF BIRTH
ETHNICITY
/
/
____________________
GENDER
_____________________
_________________________
o Black/African American
o Hispanic/Latino
o Native American/Native Alaskan
o Asian
o Native Hawaiian/Pacific Islander
o White/Caucasian
o Multiracial (please specify)_________________________________
o Other not listed (please specify)_____________________________
Note: Student’s GPA is required by the sponsor for the record only.
I attest to the fact that the above information is true and accurate to the best of my knowledge.
I understand the purpose of the STEM Club Leadership Training Summer Camp, which is to
prepare participants to start STEM Clubs during the 2016-2017 academic year in home high
schools. I agree to attend and actively participate in all activities during the summer camp. I will
comply with all rules and regulations of the camp, and I am aware that failure to comply could
result in dismissal from the camp.
I understand and willingly commit to meeting these expectations.
APPLICANT’S SIGNATURE__________________________________DATE_______________
STEM Club Leadership Training Summer Camp
Parent and Guardian Consent Form
STUDENT’S NAME________________________________________________________
first
middle
last
STUDENT
LIVES WITH:
O parents
O mother
O father
O foster parent/s
O guardian
O relatives or other (please specify)_______________________________
FATHER/GUARDIAN
FULL NAME:_________________________________________________________________________
OCCUPATION:_______________________________________________________________________
EMPLOYER’S NAME & ADDRESS:_______________________________________________________
____________________________________________________________________________________
WORK PHONE:_________________________________
CELL PHONE:__________________________________
EMAIL ADDRESS:_______________________________
MOTHER/GUARDIAN
FULL NAME:_________________________________________________________________________
OCCUPATION:_______________________________________________________________________
EMPLOYER’S NAME & ADDRESS:_______________________________________________________
____________________________________________________________________________________
WORK PHONE:_________________________________
CELL PHONE:__________________________________
EMAIL ADDRESS:_______________________________
I understand the purpose of the STEM Club Leadership Training, which is to prepare participants to start
STEM Clubs during the 2016-2017 academic year in home high schools and would like to have my child
participate.
I hereby attest that all information in this application is true and correct. I also understand that a false
statement or misrepresentation will make the applicant ineligible for the STEM Workshop.
GUARDIAN/PARENT SIGNATURE_________________________________DATE________________
HEALTH STATEMENT
Please list any and all physical conditions that the student may have which might affect or be affected by
participation in this program and which the STEM Workshop Staff should know about.
Present medical problems or conditions:
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________
Medications taken regularly:
____________________________________________________________________________________
______________________________________________________________
Allergies (including allergies to medications):
____________________________________________________________________________________
______________________________________________________________
Limitations on physical activities:
____________________________________________________________________________________
______________________________________________________________
Wears contacts?
O yes
O no
Wears glasses?
O yes
O no
MEDICAL RELEASE
For
__________________________________________
first
middle
last
A Student in the STEM Club Leadership Training Summer Camp
I do ___ I do not ___ hereby grant permission to the STEM Club Leadership Training Summer Camp
Director to furnish first aid as my child (named above) may require, as well as to seek medical attention
through the nearest medical facilities such as those provided on campus and those medical facilities
available when students are on field trips and other authorized activities.
This permission is conditioned upon the understanding that, in the event of serious illness or the need for
hospitalization and/or major surgery, the Director will use all reasonable efforts to contact me. Failure in
such efforts, however, should not prevent the Director from providing such emergency treatment as may
be necessary for the best interest of the life of my child.
PARENT/GUARDIAN SIGNATURE____________________________________DATE_______________
STEM Club Leadership Training Summer Camp
Teacher Recommendation Form
This recommendation is part of the student’s application to the STEM Club Leadership Training Summer
Camp at The University of Akron. Please evaluate the student as best you can.
Student’s Name ______________________________________________________________________
Last
First
Middle Initial
Teacher’s Name______________________________________
Teacher’s Email_____________________________
Telephone No.____________________
Subject(s) Taught to Student_____________________________
⃞current teacher
⃞past teacher
School Name___________________________________ How long have you known this student?______
School Address_______________________________________________________________________
Number & Street
City
State
Zip
Please rate the candidate
Excellent
Above
Average
Average
Below
Average
Ability to work independently
Commitment to education
Communication skill
Integrity
Interest in learning
Leadership skill
Maturity
Peer relations
Please indicate your overall evaluation of this student relative to their potential participation in The
University of Akron Science, Technology, Engineering, and Math (STEM) Workshop
⃞ I strongly recommend
⃞ I recommend
⃞ I recommend with reservation
⃞ I do not recommend
Please mail this recommendation by April 22, 2016: Dr. Julie Zhao, [email protected] College of Engineering
The University of Akron Akron, OH 44325-3901
Signature _______________________________________________________
Date ______________________