1 First Time Student Application Form - OC Honors Summer Academy

First Time Student Application Form - OC Honors Summer Academy: July 15-21, 2012Thank 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: _______________________________________School Attended: _______________________________Student Mailing Address: _________________________Social Security #:_________________________ACT Score and year taken:__________________Ethnicity: _______________________________City, State, Zip Code:Email Address: _________________________________Roommate Preference:____________________Phone Number: _________________________________ Grade in the Fall of 2012: 10 11 12Gender: M F Date of Birth_______________ Shirt Size: XS S M L XL XXLFather’s Name: ______________________________Mother’s Name:______________________________Contact Number: _________________________Contact Number:_________________________List the Extracurricular activities you have engaged in and your role: EG. Yearbook Committee-VP 2008/09Name 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 2012 Sophomores choose 2 courses: Bible 1____ Engineering 1____ Humanities 1____ Science 1___Fall 2012 Juniors choose 2 courses: Bible 2____ Engineering 2____ Humanities 2____Science 2 ________Fall 2012 Seniors choose 2 courses: Bible 3_______ Engineering 3______ Math 3_______ Music 3________1

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 17-23, 2011.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___________, 2011.Witness__________________________________________________________________________Print Name______________________________________Signature______________________________________Address_______________________________________________________________________________________________________________________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