iEngineer at UMD Summer Camp, Application, University of Maryland, Application

iEngineer@UMD Summer Camp 2010
Program Application

Application Part I: Biographical Information

Last Name:	First Name:	MI:
Home Address:
City:	State:	Zip:
Phone:	Birthdate:

Current Grade Level:

Gender:

Race/Ethnicity: (for statistical purposes only) Please check all that apply

	Asian American/Pacific Islander/Asian		Latino/a
	African American/Black		Multiracial/Multiethnic
	Caucasian/White		Other (Please specify)
	American Indian/Alaskan Native

How did you find out about this program?

	School Counselor		Science/Math Teacher
	Internet		Summer Program Fair
			Other (please specify):

School Information
Name of School:

School Address:		School City:
School State:		School Zip:
School Phone:		School Fax:

Parent/Guardian Information
Parent/Guardian Name:		Home Phone :
Daytime Phone:
Hours that I’m reachable at the Daytime Phone:
* Email Address:		* Please provide an e-mail address that you check frequently. We will be sending you regular updates and announcements regarding your application.

I acknowledge that I am the parent/guardian and by checking this box, I confirm that the information included is accurate to the best of my knowledge.

Application Part II: "About Me" Paragraph

In a short paragraph, 4-6 sentences (no more than 1000 characters), please tell us why you want to participate and what you hope to learn from this camp.

( You may enter up to 1000 characters. )

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