Bright Prospect Summer Academy Application 2017

Summer Academy 1 at Harvey Mudd, July 24th-28th.

DEADLINE TO APPLY IS MAY 19th at 3:30pm. Students will be notified with further information no later than June 23rd.

Legal First Name *
Name that appears on official government documents (Social Security, Birth Certificate, etc.)
Your answer
Legal Middle Name *
Name that appears on official government documents (Social Security, Birth Certificate, etc.)
Your answer
Legal Last Name *
Name that appears on official government documents (Social Security, Birth Certificate, etc.)
Your answer
Home Address *
(Street #, Street Name, Apt. #)
Your answer
City *
Your answer
Zip *
Your answer
Home Phone # *
(000-000-0000)
Your answer
Student Cell #: (if you don't have one, please leave blank) *
(000-000-0000)
Your answer
High School *
If High School is "Other" please list
Please list your high school if you selected other above
Your answer
Student ID #: *
(PUSD: Student ID #; Ontario students: enter your SHORT ID #)
Your answer
Email: (Personal account - NOT your PUSD e-mail) *
Your answer
High School Graduation Year *
Gender *
Birthdate *
MM
/
DD
/
YYYY
Age *
Your answer
Do you qualify for free or reduced lunch? *
Required
Ethnic Group: *
Required
Do you have, or have had, any serious illness, physical disability, chronic illness, or significant allergy? *
If yes, describe:
Your answer
Dietary concerns
Your answer
Parent or Legal Guardian's Full Name *
Your answer
Parent or Legal Guardian's Phone Number *
Your answer
Other Parent or Legal Guardian's Full Name
Your answer
Other Parent or Legal Guardian's Phone number
Your answer
Do your parents/guardians prefer information in English or Spanish? *
Emergency Contact 1 *
Please provide name and relationship
Your answer
Emergency Contact 1 Phone Number *
Please include area code
Your answer
Emergency Contact 2 *
Please provide Name and relationship
Your answer
Emergency Contact 2 Phone Number *
Please include area code
Your answer
ESSAY: Why do you aspire to go to and graduate from college? *
The essay should be approximately 250-words typed
Your answer
Please indicate the beginning and the end dates of any other summer programs you're planning to attend (e.g. Upward Bound, ROTC, Band Camp)
Your answer
I, the parent/guardian, grant permission to the applicant to view a PG-13 film. *
General Comments and/or Questions:
Your answer
Parent/guardian Signature: *
By typing in my name, I, the parent/guardian, grant permission to the applicant to participate daily in the Summer Academy; I will encourage his/her success and provide transportation to and from the program.
Your answer
Date of Parent Signature *
MM
/
DD
/
YYYY
Applicant Signature: *
By typing in my name, I certify that all of the above information is accurate to the best of my knowledge and that all signatures have been provided by their rightful signatories.
Your answer
Date of Applicant Signature *
MM
/
DD
/
YYYY
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