AVID

Application for the AVID/ESU Summer Institute

Turn in your Medical Consent Form, (which requires a notarized parent/guardian signature) to your AVID Teacher or fax to June Coleman at 620-341-5168 by May 1, 2013.

AVID Teachers: Please mail any "hard copy" applications, medical forms, and payments by May 15, 2013 to:

June Coleman
Campus Box 4014
1200 Commercial St.
Emporia, KS 66801

Cost is $25 per student. Make checks payable to: ESU Career Services.
Checks may be mailed to: Career Services, Campus Box 4014, 1200 Commercial St., Emporia, KS 66801.
Payment may also be made with credit/debit card by calling Career Services Monday-Friday, 8:00 a.m. to 5:00 p.m. at: 620-341-5407.
There is no charge for AVID sponsors/teachers. Thank you!

BOTH FORMS AND THE PAYMENT ARE DUE TO JUNE COLEMAN BY MAY 15, 2013.

Student's First Name
Student's Middle Name
Student's Last Name
Student's Date of Birth
Home Address
City
State
Zip Code
Student Email Address
Student Cell Phone Number
What is your T-Shirt size?: Small Medium Large X-Large XX-Large XXX-Large
Gender: Female Male
Will you bring your own vehicle to campus for the AVID Program?: Yes No
Your School Name
Grade for Fall 2013: Freshman Sophomore Junior Senior
Name of Parent/Legal Guardian
Parent/Legal Guardian Home/Cell Phone
Parent/Legal Guardian's Email Address
Please provide a well-reasoned justification on how this experience will benefit you and why you want to attend the AVID/ESU Summer Institute:
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