Duquesne University STAGES II

Duquesne University STAGES II

A Summer Theater Camp Program for Youth with Disabilities
Application
The application period will close at noon on May 15, 2019. Preference given to those that apply early-limited seats available. Notification for acceptance will be on or before May 24, 2019.
Student Information
Name *

First Name Last Name
Email *
example@example.com
Cell Phone Number (if applicable)

Area Code Phone Number
Gender

Female Male
Race

African-American Asian Caucasian Latino Native American Pacific Islander
School attending now *
Grade entering in Fall 2019 (must be entering 7th to 12th grade) *
Why do you wish to attend STAGES II – A Summer Theater Camp Program for Youth with Disabilities? *
Parent/Guardian Information (to be completed by parent/guardian)
Primary Guardian(s) Name *
Relationship(s) to student *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email address *
example@example.com
Best phone number(s) to reach you *
ex: 412-396-1700
What do you believe your child will gain from this program? *
Additional information or special considerations about your child
Should be Empty: