2016 Pharmacy Exploration Academy Application Form

2016 Pharmacy Exploration Academy Application Form

July25 – July 29, 2016

8:00 am – 12:00 pm

Student Information

Name

Home Address

City State ZIP

Phone Number

E-mail Address

Scrub Top shirt size Birth Date

Contact Person

Name

Phone Number Cell

E-mail 1

E-mail 2

Education Information

School

Grade Level (in the Fall)

Science Instructor

(Preference will be given to applicants whose teachers are part of LECOM’s Science Educators Academy)

Verification of Good Standing

Academics and Behavior

(Signature of parent/guardian, but prefer school teacher/official)

Registration Fees

Fees cover the cost of the book rental, instruction, food, and incidental materials.

PEA Fee -- $125

Make Check payable to: LECOM – Post 881

Mail Check to or for more information contact:

Kersten Schroeder, Ph.D., Director of Community Outreach

LECOM Bradenton

5000 Lakewood Ranch Blvd.

Bradenton, FL 34211

phone: 941-756-0690

e-mail: or

PHOTO RELEASE NOTICE

This notice is directed to parents or guardians of a high school student who has or is currently enrolled in the Human Body Explored program, the Medical Science Academy program, or the Pharmacy Exploration Academy offered by LECOM Bradenton over the past ten years.

LECOM Bradenton is developing a web site designed to illustrate the various activities of these students who participate in the two programs. We are seeking permission to include photos of the students on the web site. No names or identification of students will be made in any of the photos.

If you agree to allow use of your child’s photo, please read, sign and return the photo release form below. If you do not agree, please sign in the appropriate space and return the form below.

RETURN ADDRESS: Kersten Schroeder, Director of Community Outreach, LECOM Bradenton, 5000 Lakewood Ranch Blvd., Bradenton, FL 34211.

You may also FAX your response to941-782-5729or e-mail your response to .

LAKE ERIECOLLEGE OF OSTEOPATHIC MEDICINE BRADENTON

PHOTO RELEASE FORM

I, the undersigned, hereby agree to give the Lake Erie College of Osteopathic Medicine Communications staff permission to publish or to use in electronic media any photographic images in which I may be included, in whole or in part, taken during the Medical Science Academy, the Pharmacy Exploration Academy, and the Human Body Explored programs. I hereby waive any right that I may have to inspect and/or approve the finished photographic product.

Student Name: ______

Parent Signature: ______

I, the undersigned, do not agree to allow LECOM to use or publish photos in which I may be included.

Student Name ______

Parent Signature ______

PEAApplication Form