Conn Health I-Team Summer Workshop Application

Connecticut Health I-Team Summer Journalism Workshops
UConn (7/14-18)____; Quinnipiac (7/21-25)____; Yale (7/28-8/1)
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Address*
City*
State*
Zip*
Birth Date*

MonthDayYear
Grade entering in the fall*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Parent /Legal Guardian 2*
Relation 2*
Work Phone 2*

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Home Phone*

Area CodePhone Number
Emergency Contact Info
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2*

Area CodePhone Number
Parents Email (camper confirmation will be sent by email, if left blank it will be mailed)
Camper's Email
References: Names and phone numbers of two adults (guidance counselors, teachers, etc):

1)

2)
Electronic signature, please initials*
Should be Empty:

Connecticut Health I-Team Summer Journalism Workshops