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