Verizon Innovative Learning Program hosted by Harris-Stowe State University
Participant Application /

Applicant Information

Last Name / First / M.I. / Date
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Gender / Race/Ethnicity / Date of Birth

Education

Middle School Currently Attending
Grade Entering in Fall 2016

Parental information

Please list three professional references.
Parent’s Name
Parent’s E-mail Address / Parent’s Phone Number

Math and Science Courses taken (Please indicate grade received):

Math, science and technology related activities that you have participated in:

Preferred summer session

___ June 13 – June 23, 2016
___ July 11 – July 21, 2016
___ July 25 – August 4, 2016
T-SHIRT SIZE
___ Youth Medium
___ Youth Large
___ Adult Small
___ Adult Medium
___ Adult Large

Parents’ agreement of participation and consent

As the parent/guardian, I agree that my child will participate in the Verizon Innovative Learning Program hosted by Harris-Stowe State University. I understand that the program consists of a two week program during the summer and one Saturday per month during the academic year. I understand that this program will occur on the Harris-Stowe campus with transportation provided from agreed upon pick up and drop off points. It is my understanding that while my child is participating in this program that he is subject to the regulations of Harris-Stowe State University and the program. I understand that should a health emergency arise that I will be notified but if I cannot be reached by telephone I consent to emergency treatment for my child by HSSU nurse and/or staff of an accredited hospital as deemed necessary for his/her health and safety.
Parent Signature / Date

Please send completed applications to the following address:

Heather Bostic

Office of Title III & Sponsored Programs

Harris-Stowe State University

3026 Laclede Avenue

St. Louis, MO 63103

Fax: 314-340-3550

Email:

For additional information regarding the program please contact Heather Bostic at 314-340-3544.