Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Student: _____________________________________________________________________
Last Name First Name Gender (M/F)
_____________________________________________________________________
Address Home/Cell Phone
_____________________________________________________________________
School Grade Level Guidance Counselor
_____________________________________________________________________
City State E-mail address
Parent:
_____________________________________________________________________
Last Name First Name E-mail address
_____________________________________________________________________
Address
_____________________________________________________________________
Home Telephone/ Cell Phone/ Work Telephone
EMERGENCY CONTACT ___________________________________________________
NAME (Please print clearly) TEL/Cell number
Please list any other YSI programs the student participates/has participated in: ____________
_________________________________________________________________________
MEDICAL INFORMATION
I □give/ □ do not give permission for me/my child to be photographed or otherwise recorded during Young Scholars’ Institute program
events and activities, and for any and all such photographs to be displayed by Young Scholars’ Institute program in any medium
(books, photo albums, newsletters websites, etc.) whether now or hereafter known or developed.
___________________________________________________________________________
Signature (Parent/Guardian/Self): Date:
___________________________________________________________________________
Print Name