Duke Energy’s 2016 Summer Institute with Lander University
Application for Admission
Student Application Form- Deadline: June 3, 2016. The application is not complete without $120 payment and letter of recommendation.
Letter of recommendation can be emailed from the teacher or guidance counselor to dslimmer@lander.edu.
Student Name:
___________________________________________________________
Last
First
Middle
Preferred Name
Mailing Address: ___________________________________________________________
Street
___________________________________________________________
City
State
Zip
County
*Note: The following questions must be answered completely. However, no student will be denied admission based on race, sex, religion,
or national origin.
Phone: __________________________
Email Address: ________________________________
*Parent or Guardian email address
*Gender: Male___Female___ Birthday: _______________ Grade going to: ________________
*Ethnicity: ________________________
Parent or Guardian Name(s): _________________________________________________________
Address (if different from above): ______________________________________________________
Daytime phone number(s): ____________________
Emergency Contact: ________________
With whom do you live: Both parents___
Father___
Mother___
Other (specify) __________
Current School: _______________________________________________________________
School Address: _______________________________________________________________
Street
City
Zip
Guidance Counselor: ___________________________________________________________
Name
Phone
Email
Please circle which program(s) you are applying for. If you are applying for more than one please circle all that
apply and please list order of priority. All programs are limited to 20 seats.
th
th
Physics
Dr. David Slimmer
June 13-16 (Monday- Thursday)
rising 5 -10 grades
Forensics:
Dr. TD Maze
June 20-23 (Monday- Thursday)
rising 6 - 9 grades:
Mobile App Programming
Dr. Gilliean Lee
June 27-30 (Monday- Thursday)
rising 6 –12 grades:
Microbes and Outbreaks!
Dr. Mark Pilgrim
July 11-14 (Monday- Thursday)
rising 6 -10 grades
The Magic of Chemistry
Dr. Ralph Layland
July 18- 21 (Monday- Thursday)
rising 6 - 9 grades:
th
th
th
th
th
th
th
th
________
________
________
________
________
1. If you have taken any standardized tests, please indicate your scores:
2. If applicable, please list your class rank and GPA (if known): Rank: ____ out of _____
GPA: _____out of ____
3. Please list your extracurricular activities, both organized and individual, during the past two years
(i.e., Newspaper staff, Music, Baseball, etc.). Please include any summer workshops, camps, or
programs on your list.
____________________________________________________________________________
____________________________________________________________________________
T-Shirt Size (circle one):
Youth-M
Youth-L
Adult sizes - S
M
L
XL
XXL
Please read the following carefully and sign in the appropriate spaces provided.
For the Applicant:
MEDICAL INFORMATION
Please answer the following questions. Your response will NOT affect your acceptance. This information is needed to insure that we can
plan adequately for your health and safety.
Allergies: please list
________________________________________________________________
Diet restrictions/medications
_________________________________________________________
I hereby affirm that all the information on this application is correct
Applicant’s signature _____________________________________
Date _____________________
For the Parent or Guardian
Dukes Energy’s 2015 Summer Institute with Lander University will provide supervision of all participants for the
duration of the event beginning after registration and until dismissal on Thursday. At no time will a participant be
allowed to leave the group unattended for any reason.
My child has my permission to attend Dukes Energy’s 2015 Summer Institute with Lander University.
Parent or Guardian Signature _________________________________________________________
________ (please initial) I give permission for the staff or campus health provider to administer the following
over the counter medications: (please list all) ______________________________________
**By signing above I release the University to use any photographs for future promotions of similar programs.
Please submit along with this form, a letter of recommendation from your science or math teacher or guidance
counselor. Applications must be received by June 3, 2016. A payment of $120 is required for the programs.
Limited financial assistance may be available for families with recommendation of the school district (please ask
if you need additional information).
Application is not complete without payment and letter of recommendation. Send application materials to:
College of Science and Mathematics
Lander University
320 Stanley Ave. Box 6030
Greenwood, SC 29649
Attn: Dave Slimmer