EmailMe Form - SUMMER ENRICHMENT ACADEMY (SEA) APPLICATION

Your full legal name: Last, First, Middle, Suffix (Jr., Sr., etc.):

Birthdate

MM / DD / YYYY

Gender

Male

Female

Grade level

Social Security Number (last four numbers)

Home Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

School Name

School Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Telephone Number

### - ### - ####

Parent or Guardians Name

Parent or Guardians Telephone Number

### - ### - ####

Parent Email

Student Commitment

I understand that the understand that the Summer Enrichment Academy will be held Monday through Thursday, 8A to 4P from June 29, 2015 – August 8 , 2017, and if accepted, I intend to participate fully. Consequently, I will be prompt for, and will attend, all classes and scheduled activities. I will complete all class assignments and conduct myself according to the standards of the Code of Good Conduct of the Summer Enrichment Academy at Christ Our Redeemer AME Church, 45 Tesla Irvine, CA 92618.

Signature

Clear

Please print name here

First Last

Date Time

MM / DD / YYYY

Parent Commitment

I give my child permission to participate in the Summer Enrichment Academy at Christ Our Redeemer AME Church, 45 Tesla Irvine, CA 92618. I will attend the Parent/Student orientation and other required parent events and support my child's prompt and regular participation in the Summer Enrichment Academy. I give my permission to release my child’s academic records to the Summer Enrichment Academy for future research.

Signature

Clear

Please print name here

First Last

Date Time

MM / DD / YYYY

Applicant Name

Ethnic Identity Information

Please indicate your ethnic identity by checking the appropriate box below. Providing such information is voluntary.

If other, please specify

Grade Information

Please provide the following information.

Math course last completed

Grade

English course last completed

Grade

Science course last completed

Grade

Career/College Information

Career Interest

College Interest

Please list hobbies and/or areas of interest

Personal Statement

Please print name here

First Last

Describe yourself and include information on your background, interests, academic strengths, and any specific skills or talents.

What career and college plans have you made at this time? Discuss how you decided on your intended field of study and your level of commitment to achieving your goals.

Describe a problem that you think needs to be solved in the world today. List a possible solution to the problem?

Why do you feel it is important for you to participate in the Summer Enrichment Academy at Christ Our Redeemer AME Church, and what do you hope to gain from your participation?

Upload your report card (must be a jpg, jpeg, pdf, or png file)