2024 Summer Academy & Summer Bridge Application
Name
*
First Name
Last Name
Name You Prefer to Be Called
*
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Student Contact Phone Number
*
Please enter a valid phone number.
Student Email (be sure to use one that is available to check during summer)
*
example@example.com
Student Birthdate
*
-
Month
-
Day
Year
Date
Student High School
*
Larue County
Nelson County
North Hardin
Thomas Nelson
Washington County
Which Summer program will you be attending? (Note: Summer Bridge is only available to graduated seniors.)
*
Summer Academy
Summer Bridge
Grade as of Fall 2024
9th
10th
11th
12th
High School Graduate
T-Shirt Size (Adult XS, S, M, L, XL, 1XL, 2XL, 3XL)
Please list any allergies or dietary restrictions.
*
Who do you live with?
*
Both Parents
Father
Mother
Both Grandparents
Grandfather
Grandmother
Other Relative
Non-Relative
Foster Care
Other
Parent/Guardian Name
*
First Name
Last Name
Relationship to Student
*
Parent/Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Alternate Emergency Contact Name
*
First Name
Last Name
Alternate Emergency Contact Relationship
*
Alternate Emergency Contact Phone Number
*
Please enter a valid phone number.
By signing below, both student and parent agree that student intends to attend the ECTC UBMS Summer Academy/Summer Bridge daily, engage in all activities, and complete any work assigned. Further, student agrees to to follow program Code of Conduct and all rules and regulations set forth in the ECTC UBMS Summer Academy/Summer Bridge Student Guide.
Student Signature
*
Parent/Guardian Signature
*
This Section for UBMS Staff to Complete:
Parent/Guardian/Student Permission given verbally during telephone interview. Obtain signature later.
Please Select
Completed by R Maddox
Completed by K Glover
Completed by G Netto
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