.
Quest for the Treasure Chest: GPS
Style
.
Commuter
Academy
June 9- 13, 2008
M-F - 9:00 to 3:30 p.m.
.
Northeastern State
University
__________________________________________________________________________________________
LAST NAME (Please
Print)
First
MI
ENTERING
(GRADE) DATE OF BIRTH
__________________________________________________________________________(____)____-______
STREET
ADDRESS
CITY
STATE
ZIP
HOME PHONE
__________________________________________________________________________________________
SOCIAL SECURITY
NUMBER
COUNTY
FEMALE/MALE
RACE
(optional)
__________________________________________________________________________________________
NAME OF
SCHOOL
STREET
CITY STATE
(_____)_____-_______________________________________________________________________________
SCHOOL PHONE
NUMBER
PRINCIPAL
Please list the science and mathematics courses you would have
completed
plus any science and mathematics activities.
______________________________
(____)_________________ _____/_____/2008
Signature of
applicant
Day Phone Number
I give my permission for _______________________________ to participate
on the activities of the Quest
for the Treasure
Chest: GPS Style Summer Academy, including field trips.
In addition, I give permission for the
above participant to receive any
medical attention deemed necessary by
qualified medical personnel in the event
such treatment is required during the Academy.
______________________________
(____)_________________ _____/_____/2008
Signature of parent or
Guardian
Day Phone Number
Emergency contact name & number(s):
_________________________________________________________
Application will not be
processed unless it includes the following:
___ Two letters of recommendatoin (one from a
teacher on letterhead)
___ A transcript (if availalbe)
___ A one page statement of why you desire to attend the academy
___ Informed consent (HELMZAR form on the web page)
___ Evidence of medical and health coverage including emergency
care and hospitalization
Please return applications
and supporting material to:
Dr. Mike Wilds, NSU, 3100 East New Orleans, Bldg.
D, Broken Arrow, OK 74014