CSI: NORTHERN SUMMERACADEMY
July 9th-12th, 2012
Sponsored by the OklahomaState Regents for Higher Education
and Northern OklahomaCollege
STUDENT APPLICATION
DEADLINE: APRIL 15, 2012
PART ONE: STUDENT INFORMATION
Student Name: ______
Address: ______City ______Zip Code ______
Telephone: ______E-mail: ______
Social Security Number: ______(this is mandatory)
*Race or Ethnic Group: Caucasian ____ Asian ____ Hispanic _____ African-American ___
Native American ____ Other ______
* Gender: Female ______Male ______
* This information will be used for grant reporting purposes only.
PART TWO: SCHOOL INFORMATION
Student School: ______
School Address: ______City ______Zip ______
Grade level in school as of Fall 2012 (Circle) 9 10 11 12
List your extracurricular activities during the past two years. These may be school related or non-school related activities.
Activity / Award / YearPART THREE: STATEMENT OF INTEREST
Have you ever applied and gone to a prior CSI Summer Academy in Oklahoma? If yes, please list the academies you have attended in prior years:
Are you planning to apply for and attend more than one Summer CSI Summer Academy in Oklahoma this summer?
Write a paragraph describing why you would like to participate in this summer CSI academy:
PART FOUR: CHECKLIST FOR COMPLETED APPLICATION
_____ Completed student application form
_____ Recommendation one (from science teacher)
_____ Recommendation one (from another teacher or sponsor of extracurricular activity)
_____ Signed photo release form (requested but not required for acceptance.) Digital pictures may become part of the Academy’s web site. Please sign the standard release form giving us permission to use your photography, and include your parent’s signature if you are under 18 years of age.
RETURN TO:
Traci Schwerdtfeger
Director CSI: Northern Summer Academy
814 Kraft Street
Alva, Oklahoma 73717
CSI: NORTHERN SUMMERACADEMY
July 9th- 12th, 2012
TEACHER RECOMMENDATION FORM
To the student:
Fill out the information below for your teacher and obtain the required student and parent signatures then give this form to your teacher. *Please note that you will need to make another copy of this page and the following page for two separate recommendations by teachers.
I agree that material regarding my school performance can be released to the NorthernOklahomaCollege selection committee for the CSI: NorthernSummerAcademy.
Student Signature ______Date ______
As parent/guardian of the above-named student, I grant permission for the release of all school data necessary to support my son’s/daughter’s application to the CSI: Northern Summer Academy.
Parent/Guardian signature ______Date ______
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(Please Print/Type)
Applicant’s Name:
Last ______First ______MI __
School Name: ______
School Address: ______
City______State ______Zip Code ______
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To the teacher recommender (to be filled out by your teacher):
The student whose name appears on the cover page has applied for the CSI: Northern Summer Academy at NorthernOklahomaCollege – Enid campus. Your candid assessment of the student’s potential to gain from and contribute to this academy will be appreciated.
Your comments along with the other recommendation forms will be reviewed by members of the selection committee. We thank you for providing this important information.
Please return this form by April 15, 2012
Traci Schwerdtfeger
Director CSI: Northern Summer Academy
814 Kraft Street
Alva, Oklahoma 73717
This section to be completed by a teacher only.
Student’s Name: ______
Teacher’s Name: ______
Subject(s) Taught: ______
High School: ______
Please rate this student on the following dimensions:
Superior / Above Average / Average / Below AverageScientific Interest
Self-Discipline
Inquisitiveness
Creativity
Social Skills
Ability to work in a team
Please provide any further comments, such as how you believe this Summer Academy will benefit the student, in the space below:
Signature of teacher ______Date ______
NORTHERN OKLAHOMA COLLEGE
Traci Schwerdtfeger
PHOTO RELEASE FORM
Subject's name: ______
We, ___(insert names of parents/guardians)___ of __(insert name of minor) __, hereby give Northern Oklahoma College and their legal representatives and assigns, the right and permission to publish, without charge, photographs taken during the CSI: Northern Summer Academy.
These photographs may be used in publications, including electronic publications, or in audiovisual presentations, promotional literature, advertising, or in other similar ways.
CIRCLE ONE: Photographs MAY/MAY NOT be taken.
We hereby warrant that we are over eighteen (18) years of age, and are competent to contract in our own names.
Signature(s): ______
...... ______
Names of Above (please print): ______
Month/Date/Year: ______
Address: ______
City: ______State/Zip Code: ______
Primary contact can be contacted at (circle one): work home
Telephone: ______
(optional) E-mail: ______
Disclaimer: Above information is held in confidence and is never released or sold.