Maryland Summer Centers

Bernard J. Sadusky Interim State Superintendent of Schools

(R) means field is Required

STEP #1: 2012 STUDENT APPLICATION FORM

Last Name:

(R)

First Name:

(R)

Middle Initial:

Choice Of Center:

(R)

Section (If Applicable):

Please select the Center first.

Home Street Address/Box Number:

(R)

Town/City:

(R)

Zip Code:

(R)

Home Phone Number:

(R) (Format: 123-456-7890)

Parent Cell Phone Number:

(Format: 123-456-7890)

Parent EMail Address:

(Encouraged)

School District:

(R)

Date of Birth:

(R)(Format: MM/DD/YYYY)

Age:

(R)

Sex:

Male Female (R)

Entering Grade:

(R)

Ethnic Origin:

(R)

Name of School You Attend:

School Phone Number:

(Format: 123-456-7890)

Your school is:

Public Non-Public Home School (R)

Maryland Summer Centers Previously Attended:

1. Name of Center:
     Year:
  2. Name of Center:
     Year:

T-Shirt size:

(R) (Adult Sizes)

Do you plan to complete the Financial Assistance or Scholarship Application?:

Yes No (R)

Parent/Guardian Permission Statement:

I hereby grant permission for my child to apply to this program and to participate in the field trips sponsored by the Center. I grant permission for school officials to report my child's achievement and aptitude scores to MSC personnel. I understand that the teacher recommendations and test results will be maintained in confidence and that applications will not be returned to students. Also, I will allow my child to complete questionnaires designed to evaluate the program. I further permit my child to participate in media events designed to promote the benefits of gifted education.(R)

Yes No

Name of Parent/Guardian:	(R)
Day Telephone Number of Parent/Guardian:	(R) (Format: 123-456-7890)
Evening Telephone Number of Parent/Guardian:	(R) (Format: 123-456-7890)