APPLICATION
Duke University Summer Academy for High School Students
SUMMER 2017
Application to be completed by:
· U.S. & International Students: Current grades 9 -12 high school students
Application must be typed (not handwritten).
Please print, sign and return the Participant Agreement as directed.
The completed application may be faxed, mailed, or scanned and emailed.
Duke Summer Session
The Bishop’s House
Attention Dr. Nicki Charles
Box 90700
Durham, NC 27708-0700
Fax: 919-681-8235
Email:
The application fee of $50.00 for U.S. students and International students is payable by check, money order, or credit card.
I want to pay by credit card. Please email payment instructions to the following email address:
E-mail address
I have enclosed a check or money order payable to Duke University.
Duke Summer Academy Participant Agreement (Appendix A): Please read and sign the Summer Academy Participant Agreement. This agreement on page 7 must be signed by both the participant and the parent/guardian.
Checklist (Appendix B): Before submitting the application, please review the Checklist on page 10 to ensure you have attached all supporting documentation with appropriate signatures. We will not review the application until it is complete and payment has been received.
Applicant Information:
First Name Middle Name Last Name
Preferred First Name
Street City
State/Province Country Postal Code
Telephone
E-mail Address
Confirm E-mail Address
Male Female
Federal guidelines mandate that we collect data on the legal sex of all applicants. Please report the sex currently listed on your birth certificate. If you wish to provide more details regarding your sex or gender identity, you are welcome to do so on the follow up forms if you are admitted to the program.
Additional Information
Date of Birth (M-D-Y): ---- Citizenship:
Ethnicity (optional):
I choose to specify from the following ethnic groups:
Hispanic or Latino Black/African American White Native American/Alaskan
Asian Native Hawaiian/Pacific Islander Other
I choose not to specify
Current Grade in School: 9th 10th 11th 12th
I am part of a Group: AHEAD AMESON BRS
NEW ORIENTAL VIA ZHENYU YANG – VERITAS EDUCATION OTHER-Please specify:
Current Contact Information (Student):
Street Address
City State/Province
Country Postal Code
Telephone E-mail Address
Have any members of your family attended Duke University? No Yes
If yes, please provide the name(s), year of graduation, relationship, and email address below, if known:
1)
Name Year of Graduation
Relationship E-mail Address
2)
Name Year of Graduation
Relationship E-mail Address
3)
Name Year of Graduation
Relationship E-mail Address
4)
Name Year of Graduation
Relationship E-mail Address
Current Contact Information (Parent/Guardian):
Name – Parent Guardian #1
Street Address City
State/Province Country Postal Code
Telephone E-mail Address
Name – Parent Guardian #2
Street Address City
State/Province Country Postal Code
Telephone E-mail Address
Emergency Contact (U.S. based):
Name Relationship
Street Address City
State/Province Country Postal Code
Telephone Fax
Cell Phone
E-mail Address
Confirm E-mail Address
School Information:
Name of Current School
Street Address City
State/Province Country Postal Code
Telephone Fax
School E-mail Address
Confirm School E-mail Address
Type of school: Public Private Boarding International Home School
Have you attended a program at Duke Summer Session or Continuing Studies in the past?
No.
Yes. If yes, which one? ______
Please rank your top choices for Day Classes (The Global Entrepreneur, The Global Giver, The Global Leader, The Global Researcher, The Global Incubator)
1.
2.
Do you require a single room?
No.
Yes.
All applicants must complete the following sections and sign the Duke Summer Academy General Agreement Form (Appendix A):
I. Have you ever been placed on any type of academic or disciplinary probation?
No.
Yes. If yes, please explain (here or on a separate sheet of paper):
Please type here (approx 500 word limit). Attach an additional page if needed.
II. Have you ever been arrested or cited, regardless of the outcome?
No.
Yes. If yes, please use an additional page to provide a complete explanation including specific details of the outcome(s).
The Duke University Community Standard
Duke University is a community of scholars and learners, committed to the principles of honesty, trustworthiness, fairness, and respect for others. Students share with faculty and staff the responsibility for promoting a climate of integrity. As citizens of this community, students are expected to adhere to these fundamental values at all times, in both their academic and non-academic endeavors.
The Pledge
Students affirm their commitment to uphold the values of the Duke University community by signing a pledge stating:
1. I will not lie, cheat, or steal in my academic endeavors, nor will I accept the actions of those who do.
2. I will conduct myself responsibly and honorably in all my activities as a Duke student.
The Reaffirmation
Upon completion of each academic assignment, students will be expected to reaffirm the above commitment by signing this statement: I have adhered to the Duke Community Standard in completing this assignment.
Student Signature:______
Students' Obligation to Report Potential Cases of Academic Dishonesty
Under the Duke Community Standard, students affirm their commitment not to lie, cheat, or steal in academic endeavors, nor accept the actions of those who do.
Thus, a student who has direct knowledge of a potential case of academic dishonesty is required to:
· Provide a signed written statement of the observed behavior to Dr. Nicki Charles in The Office of Summer Session within one week of the alleged occurrence; and
· Provide the name or identity of the person(s) alleged to have committed the violation(s).
The observing student is encouraged first to speak with the person(s) alleged to have committed the violation(s) for at least two reasons: 1) to correct any misassumption about alleged act(s), and 2) to let the accused student(s) know that the situation is being reported so that the accused student(s) might choose to self-report as well. (Contacting Dr. Nicki Charles in The Office of Summer Session to accept responsibility for a violation of the Duke Community Standard prior to the reporting of an alleged offense will be considered as a positive factor in the determination of an appropriate sanction.)
Students who knowingly do not fulfill this obligation are themselves subject to sanctions.
III. **I affirm that all of the information on and associated with this form is true and complete and that if any of the information changes between now and my enrollment at Duke I will notify the Office of Summer Session within 48 hours.
**I commit myself to uphold the Duke Community Standard and the University policies that proceed from it and understand that failure to do so may result in disciplinary action, up to and including dismissal from Duke University.
______
Participant’s Signature Date
______
Parent’s Signature Date
APPENDIX A
Duke University Summer Academy for High School Students Participant Agreement
PLEASE READ THIS AGREEMENT CAREFULLY, IT IS A LEGAL CONTRACT AND AFFECTS ANY RIGHTS YOU OR YOUR CHILD / WARD MAY HAVE IF HE/SHE IS INJURED OR OTHERWISE SUFFERS DAMAGES WHILE PARTICIPATING IN THE DUKE UNIVERSITY SUMMER ACADEMY FOR HIGH SCHOOL STUDENTS PROGRAM.
Be aware that by registering your child/ward (Participant) and having him/her participate in the Summer Academy for High School Students program, you,(Parent/Guardian Name Here) ______and the Participant (Participant Name Here) ______will be waiving all claims for injuries the Participant might sustain arising out of his/her participation in the program.
Assumption of Risks: I/We have read the Summer Academy for High School Students Guide available online and all of the information associated with this application. I/We understand that participation in the Summer Academy for High School Students program is voluntary and I/We are aware that there are situations in which students will not be under the direct supervision of Summer Academy or Duke University staff members. I/We understand that the program involves excursions and off-campus activities and I/We have elected to participate in this program. As reflected by our signatures below, I/We are aware of, have discussed, and accept the risks associated with and inherent in the Summer Academy for High School Students program.
Behavioral and Academic Expectations / Dismissal from the Program: We understand that the program is academically rigorous and designed for self-motivated and responsible individuals. I/We understand that students are expected to manage their time to complete assignments both in and out of the classroom. I/We understand that there are times during the program that students will not be directly supervised by Duke staff. I/We understand the degree of supervision that will be provided and the student’s responsibility to make wise decisions concerning his/her health and safety while enrolled in the program. We understand that the Duke Office of Summer Session has the right to withdraw and dismiss any student whose behavior is inconsistent with the goals and standards of the program. Should a participant be dismissed from the program, the parent/guardian is responsible for all expenses, including but not limited to, airfare, hotels, and meals. No refunds will be issued. Students dismissed from the program must depart Duke University’s campus within 24 hours of dismissal.
Lost/Stolen Items: I/We understand that Duke University and Duke Summer Academy for High School Students are not responsible for items that are lost or stolen and that the student is responsible for his/her own possessions. I/We agree to accept responsibility for expenses incurred during the program for lost or damaged keys and cards and damages to University property caused by the student. Damages to residence hall rooms will be divided equally among roommates, if one roommate does not claim responsibility for damages. Duke Summer Session recommends that students not be in possession of valuable equipment or merchandise during the program. Should a student wish to bring valuable equipment or merchandise, Duke Summer Session recommends that this property be insured against loss, theft, or damages.
Program Evaluation: I/We agree that the student will complete questionnaires and other requests for information as part of the program’s evaluation. We also agree that photographs or video of the student taken during the program, writings, and other student work produced during the program may be used by Duke Summer Session and Duke University in reports, public information, and promotional materials.
Medical/Insurance Requirements: I/We agree to supply all necessary medical information as requested by Duke Summer Session. I/We agree to provide comprehensive health and accident insurance throughout the duration of the program. I/We agree to provide evidence of this health insurance to Duke Summer Session. I/We understand that this insurance policy must be written by a company with a U.S. address. I/We agree to cover any and all financial medical obligations and agree that Duke Summer Session and Duke University will not be financially responsible for any illnesses or injuries sustained during the Summer Academy for High School Students program.
Cancellations and Refunds: I/We have read and understand the following cancellation and refund policy - All cancellation requests must be made in writing. Before May 2: refund of 100% of the program fee, less the $500 deposit which is forfeited. May 2 - May 15: refund of 75% of the program fee, less the $500 deposit fee which is forfeited. May 16 - June 15: refund of 50% of the program fee, less the $500 deposit fee which is forfeited. June 16 - July 7: refund of 25% of the program fee, less the $500 deposit fee which is forfeited. Beginning July 8 and thereafter: No refund.ALL cancellations involve the forfeit of the $500 deposit fee. If a medical condition necessitates the participant’s withdrawal from the program between May 2 and July 14, 2017, the program will refund the paid balance minus the $500 deposit fee. The medical condition must be documented by a physician as one that prevents participation in the program. If a medical condition necessitates the participant’s withdrawal from the program while in session, the program will refund housing and dining costs on a pro-rated basis. There will be no refund for course fees or the $500 deposit. If a participant is dismissed from the program for failure to comply with the stated and published policy, the parent/guardian is responsible for all expenses, including but not limited to airfare and change fees, hotels, and meals. In the case of a dismissal, no refunds will be issued.
Release and Waiver of Liability: In return for Duke University permitting the Participant to register and participate in Summer Academy for High School Students and having read and understand the Participation Agreement, I/We voluntarily agree to the following:
A. I/We acknowledge, agree, promise and covenant with Duke University and its trustees, officers, employees, agents, and all other persons or entities involved in the Program (Releasees), and do hereby release, hold harmless, and discharge Releasees from any and all liability for any injury, death, illness, disease, and damage to Participant or his/her property which Participant might sustain while participating in the Summer Academy for High School Students program at Duke University, and I/We execute this release on behalf of and with the specific intent to legally bind us, our heirs, assigns, personal representative(s), and estate.
B. I/We further acknowledge and understand that pictures or videos taken of participants, or products created and produced by participants, may be used in Duke products, publications, web sites and/or social media channels (e.g. Facebook, YouTube), or by organizations approved Duke Summer Session and Duke University.
C. In signing this Release and Waiver, I/We acknowledge and represent that I/We have informed ourselves fully of the contents of this Release and Waiver of Liability and hold harmless agreement by reading it before we sign it, and that I/We have reviewed it and understand what it means and that I/We sign this document freely. I/We further state that there are no health-related reasons or problems which preclude or restrict the Participant’s participation in the Summer Academy for High School Students program at Duke University.
______
Participant’s Signature Date
______
Parent’s Signature Date
Important Disability-Related Information
Duke University, under the provisions of the Americans with Disabilities Act (ADA), is prepared to explore possible coverage and reasonable academic adjustments and accommodations for individuals participating in Duke academic programs. For this purpose, a student must have a physical or mental impairment that substantially limits one or more major life activities such as, but not limited to, hearing, seeing, speaking, breathing, performing manual tasks, walking, caring for oneself, and learning. Substantially limiting refers to an impairment that prevents an individual from performing a major life activity or significantly restricts the condition, manner, or duration under which an individual can perform a major life activity, as compared to the average person in the general population. Impairment does not significantly restrict a major life activity if it results in only mild limitations or restrictions.