Young Scholars’ Institute

349 West State Street Trenton, NJ 08618

Jerri L. Morrison (609) 393-3220

Executive Director info@youngscholarsoftrenton.org

High School Grades 9-12

Summer Academic Program Application
(PLEASE PRINT)

Student: _____________________________________________________________________
Last Name First Name Gender (M/F)
_____________________________________________________________________
Address Home/Cell Phone
_____________________________________________________________________
School Grade Level Guidance Counselor
_____________________________________________________________________
City State E-mail address

Parent:
_____________________________________________________________________
Last Name First Name E-mail address
_____________________________________________________________________
Address
_____________________________________________________________________
Home Telephone/ Cell Phone/ Work Telephone
EMERGENCY CONTACT ___________________________________________________
NAME (Please print clearly) TEL/Cell number

Please list any other YSI programs the student participates/has participated in: ____________

_________________________________________________________________________

MEDICAL INFORMATION

Doctor_____________________________________ Preferred Hospital________________________________________

Allergies or Medical Conditions (if none, write N/A):

Prescriptions or Medications (if none, write N/A):

I, the undersigned, do hereby authorize the staff of Young Scholars’ Institute to directly contact the persons named on this form and do
authorize the named physician/ hospital to render such treatment as may be necessary in an emergency for the health of the said
student. In the event that guardians, physicians or other named persons on this form cannot be contacted, the staff of Young Scholars’
Institute is hereby authorized to take whatever action is deemed necessary in their judgment for the health of the aforementioned
student. I will not hold Young Scholars’ Institute responsible for the emergency care and/or transportation of the said student.

I □give/ □ do not give permission for me/my child to be photographed or otherwise recorded during Young Scholars’ Institute program
events and activities, and for any and all such photographs to be displayed by Young Scholars’ Institute program in any medium
(books, photo albums, newsletters websites, etc.) whether now or hereafter known or developed.

___________________________________________________________________________
Signature (Parent/Guardian/Self): Date:
___________________________________________________________________________
Print Name