LSSU Summer Engineering Camp
Application

Personal Information:

Last Name:

First Name: Middle:

ALL COMMUNICATIONS WILL BE BY EMAIL TO THIS ADDRESS

E-mail:

Verify E-mail:

Address:

City: State/Prov.:

Zip/Postal Code: Phone:

Date of Birth(mm/dd/yyyy): Age:

Gender:Female Male

Name of Parents or Guardians:

Do you have any impairments - physical, mental or medical - that would interfere with your ability to participate in this program? Yes No

If YES, please explain and indicate if disability support services will be required. :

Academic Information:

Year in school in 2009 - 2010: 8th Fr. So. Jr. Sr.

Grade Point Average (use 4.0 scale):
ACT Score (if available) SAT Score (if available)

Name and address of school:

Courses you are currently taking :

If you intend to go to college, what area do you plan to major in? :

Extracurricular Activities :

Other Information:

Attach an essay (100 words or more) stating why you would like to attend the LSSU Summer Engineering Camp program and what you expect to gain from this experience.

Have you ever applied to an LSSU Summer Engineering Camp before?:
Yes No

If so were you :
Accepted Not Accepted Guaranteed for this year

Camp Preferences:

Please select your preferred camp date:

Women In Technology 1 June 20-25, 2010
Robotics Camp 1 July 4-9,2010
Robotics Camp 2 July 11-16, 2010

To improve your chances of selection, do you wish to be considered for the other camp if your preference is full?
Yes No

Please select your preferred plan:
Live-In (Fee $695*)
Day Student (Fee $595*)

Specific roommate requested:

• * See main page for details