Science Outreach Information
and Parent Consent
Participant Information:
School __________________Team Name or #: ____________________
Event Attending: __________________________________
Student Name: ________________________________________
Date of Birth: ________________
Gender: M or
F
Preferred Name: _______________________________________ Year of High School Graduation: ________________
Student Mailing Address: _______________________________________________________________________________
Number
Street
Apartment Number
_______________________________________________________________________________________________________
City
State
Home Telephone: (
) ______________
Zip
Student Email Address: ________________________________________
Mother/Guardian: ___________________________
Father/Guardian: __________________________________
____________________________________________
__________________________________________________
Address (if different from student)
Address (if different from student)
____________________________________________
__________________________________________________
____________________________________________
__________________________________________________
Home Phone
Home Phone
Cell Phone
Cell Phone
____________________________________________
_________________________________________________
Email Address
Email Address
School: __________________________________
School District: ______________________________________________
Have you participated in any other WKU Math or Science programs/events? Please list name of program and year
Have
you _______________________________________________________________________________________
participated in any other WKU Math or Science programs or events? Please list the name and year
attended.
attended.
(ex. Sci Olym 08)_______________________________________________________________________________
_______________________________________________________________________________________________
Is College in your future? __________ Possible College or University Choice: ___________________________________
Newspaper Release: This section must be filled out in order to have the participant’s name listed in any press releases.
I give permission for our local newspaper to be notified of my child’s participation in one of Western Kentucky
University’s Science Outreach programs/events:
YES ____________
NO ______________
Name and city of newspaper to be notified: ______________________________
Name
_____________________________
City
Parents’ names as preferred for news release: ______________________________________________________________
Parent Consent:
I understand that my child may be photographed/videotaped for documentary, educational, and public relations
purposes.
________________________________________________
______________________
Parent Signature
Date
1906 College Heights Blvd. #11075; Bowling Green, KY 42101-1075;
P: 270.745.3048, F: 270.745.3048; www.wku.edu/ogden/
john.inman@wku.edu