1 Application For Returning Students - OC Summer Honors Academy

Application For Returning Students - OC Summer Honors Academy: July 15-21, 2012Congratulations on application to the OC Summer Honors Academy.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: ___Grade in Fall of 2012: 10 11 12ACT Score and year taken: ___Roommate Preference: __Student Mailing Address: _________________________ ___Shirt Size: XS S M L XL XXLCity, State, Zip Code:__________________________________________________________________________Email Address: _________________________________ ___Phone Number: ____________________________Father’s Name: ______________________________ ___Contact Number: ___________________________Mother’s Name:______________________________ ___Contact Number:___________________________List the Extracurricular activities you have engaged in and your role: EG. Yearbook Committee-VP 2008/09Choose 2 of the 4 courses:Fall 2012 Juniors choose 2 courses:Fall 2012 Seniors choose 2 courses:Bible 2____ Engineering 2____ Humanities 2____Science 2 ________Bible 3____ Engineering 3 ______ Math 3________ Music 3________Health / Medical InformationAll information provided on this form will be used to ensure that the students enjoy the best possible experience whileinvolved with Oklahoma Christian University and the Summer Honors Academy. This information is absolutelyconfidential and will only be shared with program directors, medical staff, and the student’s individual counselor toensure the safety and well-being of the student.Medical History of Student-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 current or pastmedical conditions that may require treatment. List/describe any physical restrictions.Please describe any other medical/health concerns:1

Parent / Guardian ContactEmergency Contact Name:Phone Number:Physician ContactRelationship to Student:Alt Phone:Physician’s Name:Street:City / State / Zip:Medical Insurance InformationPolicy Holder’s Name:Policy Holder’s Employer:Insurance Company Name:Policy Holder’s Birthdate_____/_____/_____Insurance Company Phone:Policy/Group Number:Insurance Company Address:I herby agree that all information on this form and attached forms is true and correct to the best of my knowledge andgive permission for my child to attend the OC Summer Honors Academy, July 15-21, 2012.AUTHORIZATION FOR MEDICAL EMERGENCY TREATMENT: If your child sustains a non life-threatening injury,Oklahoma law requires that a hospital have parental consent before beginning treatment. This form allows you to givethe 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, authorize the staffof Summer Honors Academy to provide consent for emergency medical care for my child named above if unable toreach 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 andassigns, the right to photograph and videotape me and use my picture, silhouette and other reproductions of myphysical likeness (as the same may appear in any still camera photograph and/or videotape) in and in connection withthe exhibition on television, the internet, cassette, DVD or otherwise, of all the televisions shows, conventions, “clips”promos, magazine, newspaper articles, etc. in which my participation is included and in which the same may be used orincorporated and utilized throughout the world, and also in the advertising, utilizing and/or publicizing of any suchprogram/video as it so requires. I further give these groups the right to reproduce in any manner whatsoever anyrecordation made by said company 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 effect thereforeand, intending to be legally bound, I have hereunto set my hand this ________ day of ___________, 2012.Print NameParent or Guardian SignatureAddressPlease send a $100 deposit (applied toward the total cost; refunded if the applicant is not accepted.)2