1 First Time Student Application Form - OC Honors Summer Academy

First Time Student Application Form - OC Honors Summer Academy: July 14-20, 2013Thank you for applying to OC Honors Summer Academy. All high school students finishing their freshman,sophomore, or junior year with at least a 21 ACT/980 SAT/98 PSAT or by recommendation may apply to theAcademy. Though we would like to offer the program for all students, unfortunately, no more than 80students will be selected to participate in the program. This application form with your letter ofrecommendation from a teacher, guidance counselor or church leader and deposit will serve to differentiateyou from the other candidates, helping us to select the final participants. Questions: Call (405) 425-5300Please complete and mail forms to:Oklahoma Christian University/University Honors Academy/PO Box 11000/Oklahoma City, OK 73136-1100Please Print ClearlyName: _______________________________________ Social Security #:_________________________(required for Registrar’s office use only)High School Attended: ____________________________ ACT, SAT, PSAT Score and year taken:___________Student Mailing Address: _________________________Ethnicity: _______________________________City, State, Zip Code:Email Address: _________________________________Roommate Preference:____________________Phone Number: _________________________________ Grade in the Fall of 2013: 10 11 12Gender: M F Date of Birth_______________ Shirt Size: S M L XL XXLFather’s Name: ________________________Contact Number: ____________________Email_____________Mother’s Name:________________________Contact Number:____________________Email_____________How Did you find out about Honors Summer Academy:List the Extracurricular activities you have engaged in and your role: EG. Yearbook Committee-VP 2012/13Name a book you have read in the past year and your thoughts on the book.Please choose 2 of the 4 courses in your grade level:Fall 2013 Sophomores choose 2: Worldview____ Engineering 1__Intro to Homer__ History of Science____Fall 2013 Juniors choose 2 courses: History of the Bible__Engineering 2____Holocaust Lit____Cell Bio____Fall 2013 Seniors choose 2 courses: Intro to Luke____Engineering 3_____Math/CS____ Intro to Music_____1

Health / Medical InformationStudent NameAll information provided on this form will be used to ensure that the students enjoy the best possibleexperience while involved with Oklahoma Christian University and the Summer Honors Academy. Thisinformation is absolutely confidential and will only be shared with program directors, medical staff, and thestudent’s individual counselor to ensure the safety and well-being of the student. This information has nobearing on the student’s acceptance. Our desire is to ensure that all students are healthy and safe whiledeveloping their leadership abilities through this program. We are committed to working with all studentswho display leadership potential and are happy to make an extra effort to ensure that students with healthconcerns or disabilities achieve the maximum effect from the program.Medical History of StudentDate of Last Tetanus shot:Please check relevant items:Diabetes Drug Allergy Physical restrictionsFood Allergy Insect Bite Allergy AsthmaHeart Defects Convulsions/Epilepsy Currently taking medicationPlease list details for items checked above; indicate medications that student is taking, and any other currentor past medical conditions that may require treatment. List/describe any physical restrictions.Please describe any other medical/health concerns:Parent / Guardian ContactEmergency Contact Name:Relationship to Student:Phone Number:Alt Phone:Physician ContactPhysician’s Name:Street:City / State / Zip:Medical Insurance InformationPolicy Holder’s Name:Policy Holder’s Employer:Policy Holder’s Birthdate_____/_____/_____Insurance Company Phone:Insurance Company Name:Policy/Group Number:2

Insurance Company Address:I herby agree that all information on this form and attached forms is true and correct to the best of myknowledge and give permission for my child to attend the OC Summer Honors Academy, July 14-20, 2013.AUTHORIZATION FOR MEDICAL EMERGENCY TREATMENT: If your child sustains a non life-threateninginjury, Oklahoma law requires that a hospital have parental consent before beginning treatment. This formallows you to give the necessary permission, even if your child is under the care of another adult.I (we) the undersigned parent(s) or legal guardian(s) of ____________________________, a minor, authorizethe staff of Summer Honors Academy to provide consent for emergency medical care for my child namedabove if unable to reach me.SignedDatedPrinted NameAUTHORIZATION TO UTILIZE PHYSICAL LIKENESS:NON-UNION PRODUCTIONI expressly grant to Oklahoma Christian University, the University Honors Program, and to their employees,agents and assigns, the right to photograph and videotape me and use my picture, silhouette and otherreproductions of my physical likeness (as the same may appear in any still camera photograph and/orvideotape) in and in connection with the exhibition on television, the internet, cassette, DVD or otherwise, ofall the televisions shows, conventions, “clips” promos, magazine, newspaper articles, etc. in which myparticipation is included and in which the same may be used or incorporated and utilized throughout theworld, and also in the advertising, utilizing and/or publicizing of any such program/video as it so requires. Ifurther give these groups the right to reproduce in any manner whatsoever any recordation made by saidcompany of my voice and all instrumental, musical, or other sound effects produced by me.I hereby certify and represent that I have read the foregoing and fully understand the meaning and effecttherefore and, intending to be legally bound, I have hereunto set my hand this ________ day of___________, ______.______________________________________Print Student Name______________________________________Address______________________________________City, State Zip Code_________________________________________________________________________________Parent or Guardian Signature if Subject is Under 21 years of agePlease send the following to complete your application:1 A copy of your current High School Transcript;2 $100 deposit (applied toward the total cost; refunded if the applicant is not accepted);3 A letter of Reference from a teacher, guidance counselor, or church leader if you havenot taken the ACT/SAT/PSAT or it is below a 21/980/98.3