1.Student Name (First Name, Last Name)

2.Student Age

13 years old

14 years old

15 years old

16 years old

17 years old

18 years old

3.Parent/Guardian Name (First Name, Last Name)

4.Parent/Guardian Cell Phone

5.Mailing Address (Street, City, Zip Code)

6.Question for Student: Please tell us why you are interested in this program and what you hope to get out of this experience.

7.Does the student have any dietary restrictions?

8.Does the student have any allergies? Please let us know if the student requires any medical treatment during the program (allergy medicine, etc)

9.May we use photos or video which include your student in Westcott communications?

Yes

No

10.Students who receive the scholarship will receive a free tuition to this program. Please certify that the student will make an effort to attend all the sessions.

The scholarship will make it possible for my child to attend the program.

My child will make an effort to attend all the sessions.

11.At the end of the program we will ask each student to write a short testimonial evaluating the value of the program (we will use testimonials to communicate the impact of our programming to our constituents and seek grant funding to offer scholarships for future programs)

The student commits to contributing a short testimonial/evaluation at the end of the program