Summer Programs for High School Students Confirmation of Enrollment Form
Welcome to Northeastern University’s Summer Programs for High School Students! In order to confirm your decision to attend
our program, you and your parent/guardian must read over the following guidelines and sign and return both forms. Please read the
guidelines outlined here with care. We need student and parent/guardian signatures completed on these forms to finalize your
enrollment.
STUDENT INFORMATION – Please Print
Student’s Name:
Gender:
Male
Female
Home Address:
City/State/Zip/Country:
Date of Birth (mm/dd/yy):
Social Security Number:
Parent/Guardian Name(s):
Home Phone:
Student Cell:
Parent/Guardian Day Phone:
Evening Phone:
Student Email:
Parent/Guardian Email:
STUDENT
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I, the student, acknowledge that I shall attend the 2013 Summer Programs for High School Students (check the appropriate box below) and
hereby certify that I have read and will abide by the program policies. See the Policies section on our web site:
http://www.cps.neu.edu/college-summer-programs/.
☐ The College Prep Experience
Student Signature:
☐ Summer Seminar
☐ College 101
Date:
PARENT/GUARDIAN

I confirm that my son/daughter/ward will attend the 2013 Summer Programs for High School Students, and also hereby certify that I have read
the program policies– (see the Policies section on our web site: http://www.cps.neu.edu/college-summer-programs/), and agree that my
son/daughter/ward will abide by these policies. In consideration of Northeastern University allowing my son/daughter/ward to attend the
program, I hereby release Northeastern University, its Trustees, Corporators, faculty, staff, students and agents from and against all legal and
financial responsibility arising from my child/ward’s participation in the 2013 Summer Term Pre-College Program. I hereby assume all legal and
financial responsibility for my son/daughter/ward’s involvement in the program.
Parent/Guardian Name (Please print):
Parent/Guardian Signature:
Date:
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CODE OF CONDUCT AGREEMENT HIGHLIGHTS
GUIDELINES FOR STUDENTS
The Summer Programs for High School Students expects all participants to comply with the policies outlined by the Student Code of Conduct and the
Summer Programs for High School Students Handbook. Students are also expected to know and abide by Northeastern University’s policies and
procedures, and the rules and regulations that govern housing which can be found in the Guide to Residence Hall Living.
http://www.northeastern.edu/reslife/policies/index.html. Summer Program students are bound by additional guidelines as stated in the Summer
Programs for High School Students Handbook.
In order to ensure that the summer program can dedicate itself fully to its academic and educational mission, students are expected to adhere to
all University rules and regulations. The purpose of the Summer Programs for High School Students Handbook is to set expectations of behavior
that promote the safety and welfare of the Northeastern University community. The University seeks to provide a supportive environment that is
conducive to learning, the pursuit of truth, the exchange of knowledge, the intellectual development of students, and the general good of society. In
those instances where violations of the behavioral expectations occur, Northeastern University has developed policies and procedures to protect the
rights of members of the University community, individually and collectively.
Students in the Summer Programs for High School Students seek to have a challenging, engaging academic experience as active participants in the
learning process.
Students are expected to download and read the Summer Programs for High School Students Handbook from the program web site:
http://www.cps.neu.edu/college-summer-programs. Failure to abide by the policies and procedures will result in disciplinary action, which may
include, but is not limited to: a warning, probation, consultation with parent/guardian, or in cases of serious or repeated behavioral problems,
dismissal from the program. Financial obligations arising from dismissal from the program, including travel costs, are the responsibility of the
student and parent/guardian. Should a student be dismissed from the program for any reason, tuition, fees, room and board charges, and any
other program-related expenses will not be refunded and course credit will not be awarded.
Of special importance within the Summer Programs for High School Students policies and procedures, the following topics warrant direct
attention:
Respect for Others. Northeastern University is a community that consists of people of different backgrounds and beliefs. Conduct that is disruptive,
disrespectful or in violation of the rights of others, including but not limited to, verbal, physical, or sexual harassment, intimidation, and bias-related
graffiti will not be tolerated and may result in disciplinary action, including dismissal from the program.
Illegal Substances. Possession, use, distribution or being in the presence of alcohol and/or illegal drugs is not permitted. Violation of this policy is
grounds for disciplinary action and may result in dismissal from the program.
Curfew. Students must check-in with their Residential Assistant by 10:00PM Sunday-Thursday, and 12:00AM Friday and Saturday. Students must
remain on their floor unit until 6:00am. Violation of this policy is grounds for disciplinary action and may result in dismissal from the program.
Overnight Leave. Students who wish to have overnight visits to family or friends off-campus must have written permission of a parent or guardian
and notify their Program Resident Director in advance. Overnight Leave forms are available on our web site to download or with the Program
Resident Director.
Motor Vehicles. Residential Summer Program for High School Students participants are not permitted to have cars on campus. Commuter
students will need to take public transportation or be dropped off and picked up at a designated location on campus.
Damage or Loss. Students are expected to respect the property of the university. Students shall assume all financial responsibility for loss or
damage they cause to the property of the university. The responses to damaged/lost university property may include replacement, clean-up, and
labor costs. Students shall assume all financial responsibility for loss or damage caused by their guests. When individual responsibility cannot be
ascertained for damages or loss in the residence areas, students assume collective responsibility.
Health & Safety Inspections. Residential staff conducts room inspections that are designed to seek out and correct potentially dangerous situations
before they cause damage or harm. If in the reasonable course of such an inspection other violations of the Summer Programs rules are observed,
they may be reported to the Assistant Dean of Summer Term and subject to disciplinary action. Northeastern University reserves the right to enter
residence hall rooms without the consent of the occupant in order to provide for the general well-being and protection of the community, its
members and property.
Smoking. Northeastern mandates a smoke-free environment. There is absolutely no smoking anywhere in the residence halls, including in student
rooms, the lounges, lobbies, balconies, bathrooms, hallways, and the dining halls, nor is there smoking allowed within 35 feet of the residence halls,
classrooms, or offices on campus. Smoking is also prohibited at summer program sanctioned events. Failure to adhere to this policy may result in
disciplinary action including notification of the student’s parent/legal guardian.
Note: It is required that the student and a parent read the Summer Programs for High School Students Handbook , sign the Confirmation of
Enrollment Form and return the signed form to Summer Programs for High School Students Coordinator or designee.
PLEASE REVIEW AND SIGN PAGE 3
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PHOTO AUTHORIZATION AND RELEASE
Northeastern University and its representatives on occasion take photographs and/or video for the University’s use in print and electronic
publications.
This serves as a notice of the University’s intent to do so and as a release to the University as permission to use such images as it deems fit.

PERMISSION AUTHORIZED I hereby give permission to Northeastern University to take photographs and/or video of my child during this
year’s summer program and to use the images so taken in whatever way Northeastern University shall choose. By this authorization I agree
that neither I, nor my child, shall receive any fee and that all rights, title, and interest of the images and use of them belong to
Northeastern University.
I further release and indemnify Northeastern University, including the Corporation, its Trustees, faculty, employees, staff, and other agents
from and against any and all liability and responsibility for any claim or cause of action on account of any damages, expenses, or other loss
caused, suffered, or occurred during, arising out of or in any way associated, directly or indirectly with my child’s appearance in the
photographs, the make of such images, and/or their use.

PERMISSION DENIED I hereby deny permission to Northeastern University to release photographs and/or video of my child during this year’s
summer program.
PARENT/GUARDIAN
I understand that each year, during the course of the Summer Programs for High School Students, educational and recreational activities are
offered to participate in away from the Northeastern University campus, any one or more of which my son/daughter/ward may take advantage at
his/her option. These Activities include, but may not be limited to daytrips to destinations such as; points of interest in Boston and the surrounding
area, to Newport, RI,, shopping outlets, museums, and New England colleges. These Activities will include transportation arranged by Northeastern
University. I understand that Program staff accompany the off-campus Activities and supervise participants’ movements at the off-campus site/s. I
also understand that the Activities, visiting these sites, travel to and from these sites, and the various activities at these sites present a risk to my
son/daughter/ward. These Activities may result in personal injury, accidents or illnesses (including death), and property loss. I have read the
previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the Activities I hereby assert that my
son/daughter/ward’s participation is voluntary and that I knowingly assume all such risks.
I acknowledge that each of the ACTIVITIES is a voluntary exercise and that my son/daughter/ward’s participation is not required for successful
completion of the Summer Programs for High School Students and acknowledge that I have been advised that any decision not to participate in
each of the Activities will not have any impact on my son/daughter/ward’s evaluation or grade in the Summer Program. I further acknowledge
that my son/daughter/ward’s participation in each activity is subject to any and all rules, procedure, and regulation outlined for us by the
Northeastern University personnel and/or any person(s) conducting, leading, and/or directing the activity.
In consideration of Northeastern University’s permitting my son/daughter/ward to participate in the Activities I also agree to INDEMNIFY AND
HOLD Northeastern University its Trustees, Corporators, Officers, Faculty, Staff, Students and Agents HARMLESS from any and all claims,
actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my son/daughter/ward’s
participation in each of the Activities. I do hereby release and forever discharge Northeastern University its Trustees, Corporators, Officers,
Faculty, Staff, Students and Agents from all liability and responsibility for any claim or cause of action for any personal injury, accident, damage,
expenses, or other loss caused, suffered, or incurred to me or my son/daughter/ward during, or arising out of, my son/daughter/ward’s
participation in each of the Activities.
For the benefit of Northeastern University, I, the undersigned, acknowledge that my son/daughter/ward is participating in the Summer Programs for
High School Students offered by Northeastern University. I understand that my son/daughter/ward’s participation in each course and/or activity
associated with each course is subject to any and all rules, procedures and regulations - see the Academic Code of Conduct and Guidelines section
on the Summer Programs for High School Students web site and Handbook, and by Northeastern University personnel and/or any other person(s)
conducting, leading and/or directing the course/activity. Further, I acknowledge that I have read and fully understand the above statements and
that if I am unable to do so, for whatever reason, I have had them read to me and am confident that the individual has read and/or translated the
statements truthfully and in their entirety. This release and waiver has been executed on behalf of myself and my son/daughter/ward, and has been
made with full knowledge of possible risks involved.
Student Name (Please print):
Parent/Guardian Name (Please print):
Parent/Guardian Signature:
Date:
[Over]
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Retain a copy of your signed acceptance form for your records. Please fax to (617)-373-8574 or mail the signed form to:
Northeastern University
Summer Programs for High School Students
Office of Admissions
50 Nightingale Hall
360 Huntington Avenue
Boston, MA 02115-9959
If you have any questions regarding these forms or any of the policies covered within, please contact the Summer Programs for High
School Students office at (617)-373-2400, Ext 17.
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