CSU OPEN DOORS REGISTRATION FORM

CSU Open Doors is an initiative developed by CSU in response to the impending CPS strike slated to begin on October 11, 2016. Chicago State University will open it's doors to 300 CPS High School students to offer academic workshops in the areas of Math, English, Science and a variety of college preparedness activities. The overall goal of the initiative is not only to provide a place for CPS High School students to go during the strike, but to expose students to the power of a university education, Social Justice and their own Personal Development. We also want them to have fun with a college experience!

Instructions: Complete the online Registration / Parental Permission Form
(Incomplete Registration forms will not be processed)
Please complete the registration form below. There will be limited on-site registration on October 11, 2016. Parents must be present to register students on site. Students without a parent or guardian will be sent home.

Question Title

* 1. Student Last Name

Question Title

* 2. Student First Name

Question Title

* 3. Home Street Address

Question Title

* 4. Zip Code

Question Title

* 5. Telephone Number (000-000-0000)

Question Title

* 6. Date of Birth (00/00/0000)

Question Title

* 7. Gender

Male

Female

Other

Question Title

* 8. Ethnicity

Black, Non-Hispanic

White, Non-Hispanic

Hispanic

Asian or Pacific Islander

American Indian/Alaskan Native

Other

Question Title

* 9. US Citizen

Yes

Question Title

* 10. List any language OTHER THAN ENGLISH spoken at home

Spanish

Other (please specify)

Question Title

* 11. CPS High School Name

Question Title

* 12. CPS Student ID

Question Title

* 13. Current Grade Level

Freshman

Sophomore

Junior

Senior

Question Title

* 14. High School Counselor Name

Question Title

* 15. Parent Name

Question Title

* 16. Parent Contact Number (000-000-0000)

Question Title

* 17. Parent/Guardian Email Addess

Question Title

* 18. Emergency Contact Name

Question Title

* 19. Emergency Contact Relationship

Question Title

* 20. Emergency Contact Number (000-000-0000)

Question Title

* 21. Second Emergency Contact Name

Question Title

* 22. Emergency Contact Relationship

Question Title

* 23. Second Emergency Contact Number (000-000-0000)

Question Title

* 24. Is your student eligible for the Illinois Free Lunch and Breakfast Program?
(If yes, additional documentation may be required.)

Illinois Free Lunch and Breakfast Programs
(23 IL Administrative Code Section 305.10)
Section 305.10 addresses requirements for school districts and others that receive state
reimbursement under the Illinois Free Lunch and Breakfast Programs. The rules clarify the
requirement of all public schools to offer a free meal (lunch required, and breakfast required if the
school operates a free breakfast program) to students eligible to receive such meals as determined
under the regulations governing the federal School Breakfast Program and the National School Lunch
Program.

Yes

Question Title

* 25. My student needs academic support in the following areas:

Arithmetic Essentials (Multiplication, Division, Fractions, Decimals, etc.)

Algebra

Geometry

Trigonometry

Statistics

Pre-Calculus/Calculus

Biology

Chemistry

Physics

English

Essay Writing

Question Title

* 26. My student is interested in the following: (Select up to three)

Radio/ Television Broadcasting

Pharmacy

Business/ Entreprenuership

Poetry/ Spoken Word

Fraternity Sorority Life

Student Council

Social Justice Issues

Modeling

Brazilian Jiu Jitsu & Aikido

Cheerleading

Dance

Male Mentoring

Female Mentoring

Physical Education and Recreation

Pre-Law

Accounting

Nursing

Hispanic Alliance

Question Title

* 27. My student is a senior and interested in admission to CSU

Yes

Question Title

* 28. Transportation: My Child will...

Take Public Transportation to Chicago State University

Be dropped of by a parent or licensed adult ( We will need a temporary Drop Off Parking Permit)

Question Title

* 29. CHICAGO STATE UNIVERSITY Open Doors Initiative Student Commuter Policy

I understand and acknowledge that my son/daughter will travel to CHICAGO STATE UNIVERSITY and return home on his/her own accord to participate in the Open Doors initiative. As the parent/guardian I will take full responsibility for my son/daughter travel needs to and from CHICAGO STATE UNIVERSITY, daily. Further, I understand that my son/daughter is to arrive at CHICAGO STATE UNIVERSITY’s Jones Convocation Center (JCC) by 8:15 a.m. CST and check in with the Open Doors staff, and that he/she will depart form the same location at 2:30 p.m., daily. Students traveling by bus will be escorted the CTA bus turn around at CHICAGO STATE UNIVERSITY and students being picked up by car will be escorted to JCC parking lot B12 by a CSU team member.

Parent/ Guardian Signature

Question Title

* 30. I agree to waive and release Chicago State University, their trustees, officers, employees, agents, and representatives from all liability, claims, or causes of action of any kind or nature (including injury, death, or other damages occurring while traveling to or from the activity) which my son/daughter may suffer or cause another person to suffer as a result of his/her participation in the above activity.

Agree

Parent/Guardian Signature

Question Title

* 31. This authorization shall remain in effect until the end of the CSU Open Doors 2016, unless sooner revoked in writing of my son/daughter’s participation in the Chicago State University’s Open Doors initiative.

Agree

Parent/Guardian Signature

Question Title

* 32. I have read and understand the terms used in this Commuter Student Travel Policy and their significance. I am authorized to sign this Student Travel Policy Form on behalf of my son/daughter.

Agree

Parent/Guardian Signature

Question Title

* 33. List any prescription medication your student is currently taking

Question Title

* 34. MEDICAL RELEASE

I hereby give my son/daughter while he/she is enrolled in Open Doors, permission to participate in all program sponsored activities. I also grant my permission for any routine or preventive or otherwise necessary medical care to be performed, as required, by an attending physician, dentist or optometrist. (I understand, of course, that I or another member of my immediate family will be contacted immediately in the event of any emergency of illness, including surgery.) In addition, I will notify a member of Chicago State University’s Open Doors initiative administrative staff of any physical or emotional problems that my son or daughter may have that will prevent or limit his/her participation in any program activities.

Parent/Guardian Signature

Question Title

* 35. My student has the following allergies

None

Peanuts/Tree Nuts

Shellfish

Other (please specify)

Question Title

* 36. Dietary Restrictions

None

Other (please specify)

Question Title

* 37. RELEASE OF LIABILITY

Also, in consideration of my son’s/daughter’s participation in Chicago State University’s Open Doors initiative, I release and discharge Chicago State University, their trustees, officers, employees, agents, and representatives from any and all liabilities, actions, causes of actions, debts, claims, and demands of whatsoever kind nature which may arise out of or in connection with the Open Doors. This Medical Release and Release of Liability shall be binding on the undersigned, any and all heirs, and personal representatives.

The undersigned, as the parent or legal guardian of the above designated Chicago State University’s Open Doors participant, who is under the age of 18 years, hereby executes this document and agrees to be bound by all of the terms and conditions stated above.

Parent/ Guardian Signature

Question Title

* 38. Photographic Consent Release Form

I understand and give my consent that any photos of my child participating in the Project FAME/Upward Bound program and Chicago State University activities/events may be used in any publication, multimedia production, display, advertisement or worldwide web production. I, the undersigned, releases and forever discharges Project FAME/Upward Bound, Chicago State University and its employees from any and all claims and demands arising out of or in connection with the use of said photographs/images, including but not limited to, any claims for invasion of privacy of defamation. Accepted and Agreed:

Parent/Guardian Signature

Question Title

* 39. Please provide any additional information that might impact your student's experience here at CSU.

Question Title

* 40. Are you a currnet member of the CSU community?

Current CSU Student

CSU Faculty Member

CSU Staff/Administrator

CSU Alum