Morgan State University School of Engineering STEAM Labs Summer Camp
Application Form

Application FEE: $50.00/week (Cash only due on the first day of camp if accepted)
Camp Hours: 9am – 5pm (M-F) (Free Lunch will be provided on a daily basis)
Last Name: *
First Name: *
Middle Name
Gender *
Street Address: *
City: *
State: *
Zip: *
Telephone: *
Contact person in case of emergency: *
Home Telephone: *
Work Telephone:
Social Security Number or MSU Student ID: *
Date of Birth (mm/dd/yyyy): *
Middle School or High School Name, Address, City, State, Zip: *
School grade in Fall 2012: *
Reference: *
(Teacher, Counselor) Name, Phone Number, E-mail
Community College Name, Address, City, State, Zip:
Total number of credits completed:
Email Address: *
(We require your email address or your parent’s email address. We will not be able to process your application without an email address.)
List all the math and science courses taken in Middle, High School or Community College: *
List all previous math, science, and technology related activities, science fairs, etc… that you have participated in Middle, High School or Community College: *
Select your camp dates: *
Parents’ Agreement of Participation and Consent:
As the parent/guardian, I agree to be involved in the on-line summer course program with my daughter/son for the Summer 2012. I understand that this course is an off-campus course, but will require weekly visits to Morgan State University for assessment and assistance (only if student resides in the Baltimore area). It is my understanding that while my daughter/son is at the University, she/he will be subject to the regulations of MSU and the Program. I understand that should a health emergency arise, I will be notified, but if I cannot be reached by telephone, such medical treatment as deemed necessary by competent medical personnel will be authorized.
This section must be signed by a Parent/Guardian:
Print Full Name (Parent):
Parent Signature
This section must be signed by the Student:
Print Full Name (Student): *
Student Signature
Date: *
Application Deadline: June 4, 2012
For additional information, contact (Email preferred) to:

Dr. Yacob Astatke (Program Director)
(443) 885-4208
Morgan State University - School of Engineering
1700 East Cold Spring Lane, Baltimore, Maryland 21251
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