APPALACHIAN REGIONAL COMMISSION/
OAK RIDGE NATIONAL LABORATORY
OAK RIDGE ASSOCIATED UNIVERSITIES
2014 MIDDLE SCHOOL SUMMER SCIENCE ACADEMY
July 13 – 18, 2014, Oak Ridge, Tennessee
PLEASE PRINT ALL INFORMATION USING BLACK OR DARK BLUE INK.
Name ______Male ______Female ______
Last First FULL Middle Name
(or use NMN if no middle name)
Social Security Number ______-______-______U.S. Citizen* ______
Yes No
Date of Birth* ______
Month Day Year
School Name ______
School County ______
School Address ______
Street City State Zip Code
School Telephone Number ______School Fax Number ______
Area Code & Number Area Code & Number
Home Address ______
Street City State Zip Code
Home Telephone Number ______Applicant’s Cell Phone Number ______
Area Code & Number Area Code & Number
Preferred E-Mail Address
(please print clearly)
Alternate E-Mail Address
(please print clearly)
T-shirt size (circle one): S M L XL XXL XXXL (adult sizes)
______
Signature of Applicant Date
Page 1 of 2
All applicants must complete both pages of this application.
Applications must be postmarked on or before February 26, 2014.
ARC/ORNL/ORAU 2013 Middle School Summer Science Academy dependent upon availability of funding
MIDDLE SCHOOL SUMMER SCIENCE ACADEMY
Name ______
Last First FULL Middle Name
(or NMN if no middle name)
Current School Grade* ______
Parent/Guardian 1 Name ______Address ______
Street State Zip Code
Parent/Guardian 2 Name ______Address ______
Street State Zip Code
q Have you participated in a hands-on math
or science camp on a previous occasion?* ______
Yes No
If your answer to the above question is yes, please complete the following:
· Name of camp you attended:______
· Where was the camp held?______
· When did you attend? ______
· Name of organization sponsoring the camp: ______
· Were you nominated to attend? ______; By whom? ______
Yes No
______
q Are you planning to attend college or other post-secondary school? ______
Yes No Not sure yet
q Did either of your parents attend college or university? ______
(Check ‘yes’ if they attended, whether or not they graduated.) Yes No
q If you have older brothers or sisters, have any of them attended college or university?
______
Not Applicable Yes No
q Does your school have access to the Internet? ______
Yes No
q Do you have access to the Internet at home? ______
Yes No
Page 2 of 2
Please attach to page one
Applications must be postmarked on or before February 26, 2014.