Student Application Form

Student Information
First Name _________________  M.I. ______ Last Name __________________
Age _________ Date of Birth _______________ Sex _____________
Social Security # ________ - ________ - _________
Address ____________________________________________________
City ___________________ State ___________ Zip Code ______________
Applicant's School ______________________
Applicant's Health Concerns (Please explain on separate if needed) ________________________________________________________________

Parent or Guardian Information
First Name __________________ M.I. ______ Last Name __________________
Address (If different from above) _________________________________________
City ___________________ State ___________ Zip Code _______________
Work Phone ______ - ______ - ________ Home Phone ______ - ______ - ________
Email _______________________ Company Name __________________________

Emergency Contact (Other Than Parent/Guardian)
First Name __________________ M.I. ______ Last Name __________________
Address _______________________________________________________
City ___________________ State ___________ Zip Code _______________
Work Phone ______ - ______ - ________ Home Phone ______ - ______ - ________
Email _______________________ Company Name __________________________

Please Select the Desired Summer Camp Session(s)
1. Microsoft Office 6/23-7/25, 2003          2. Web Page Design 6/23-7/25, 2003
3. Using Internet 7/7-8/8, 2003                 4. Computer Hardware 7/7-8/8, 2003
5. China Tour  7/22-8/5, 2003                   6. 7/29-8/30, 2001 2:00pm-5:00pm

Other Comments and/or Requests
_________________________________________________________________
_________________________________________________________________

Parent/Guardian Signature ________________________Date __________
Student Signature ________________________________Date __________