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B.E.S.T. SUMMER PROGRAM 2015: APPLICATION INSTRUCTIONS

List of documents included in the application package

1) Application instructions (this document);

2) B.E.S.T. 2015 student application form;

3) B.E.S.T. 2015 consent and release;

4) B.E.S.T. summer program information sheet;

5) Health requirements form.

Application Instructions

To apply for the program, please submit the following documents by April 15, 2015:

• Completed ‘B.E.S.T. 2015 student application’ form;

• Completed ‘B.E.S.T. 2015 consent and release’ form (completed by parent/guardian if you are under the

age of 18);

• Official transcript(s) from home institution.

Application Submission

Please email Jia Jia Wei at jwei01@udayton.edu the following documents:

• Scanned/electronic copy of completed ‘B.E.S.T. 2015 student application’ form;

• Scanned/electronic copy of completed ‘B.E.S.T. 2015 consent and release’ form (if applicable);

• Scanned/electronic copy of official transcript(s) from home institution.

Please send your official transcript(s) from your home institution via post to:

Raji Ananthraja

Assistant Director of International Admission

Office of International Admission

University of Dayton

300 College Park

Dayton, OH

U.S.A. 45469-1671

Please bring your completed health requirements form with you to the University of Dayton for collection upon

arrival.

Summer 2015 B.E.S.T. Program: Student Application

The University of Dayton's B.E.S.T. program is a special blend of academic and hands-on learning centered

around business, engineering, science and technology.

You'll spend four weeks on campus, learning from University of Dayton professors as you immerse yourself in

the university experience.

To be eligible for consideration as a B.E.S.T. student, you must have completed at least their sophomore

year of high school.

Section 1: Student Information

Last Name:

First Name:

Middle Name:

Date of Birth (mm/dd/yyyy):

Gender Male Female

Are you a U.S. citizen or

permanent resident?

Yes No

If no, what are your citizenship

and visa statuses?

Email Address:

Phone Number:

Permanent Address:

Mailing Address:

(If different from above)

Section 2: Educational Background (Home Institution)

Current High School:

Address of High School:

First Attended (mm/dd/yyyy):

Last Attended (mm/dd/yyyy):

(Leave blank if still attending)

Expected Graduation Date:

Your Intended College Major:

PARENTAL/LEGAL GUARDIAN CONSENT (If under 18 years of age)

As parent/legal guardian of this student, I authorize him/her to travel to the University of Dayton in Dayton,

Ohio, for the B.E.S.T. program offered from July 6 to July 31, 2015. I acknowledge that this student has major

medical insurance that will cover this child for medical treatment in the United States. I authorize the University

of Dayton to make medical treatment decisions for the student in cases of emergency. In addition, emergency

contact information is provided:

Name:

Address:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

Signature of Parent/Guardian:

Date:

TO BE COMPLETED AND SIGNED BY THE GUIDANCE COUNSELOR OFFICIAL

He/she has been given approval to take courses at the University of Dayton during Summer 2015.

Name of High School:

School CEEB Code:

Counselor Name:

Email Address:

Phone Number:

School District:

Student's Class Standing:

(_____ of _____)

GPA (out of 4.0):

Would you recommend this student as having the aptitude and academic record appropriate to study at the

University of Dayton in the B.E.S.T. program?

Please state any evidence to

support your

recommendation:

Signature:

Date:

University of Dayton

300 College Park

Dayton, OH

U.S.A. 45469-1671

INFORMED VOLUNTARY CONSENT AND GENERAL RELEASE

(For parent/guardian signature of participants under age 18)

In consideration of participation in The University of Dayton activity/program as described herein, and having

actual knowledge and appreciation of the particulars of the program and those risks involved in this type of

activity/program, I, on behalf of my child, voluntarily consent to use of the facilities and participation in the

activities/programs at this site, and assume all the risks arising therefrom.

Group Name: B.E.S.T. Summer 2015

Description: Enrollment Management – B.E.S.T. Summer 2015 Program

Location: University Summer Conference – University of Dayton Release

Date(s) of Activity/Program: July 6-31, 2015

I hereby declare that my child is in good health and has no mental or physical condition or symptoms that could

interfere with her/his safety or the safety of others while participating in any activity using any equipment or facilities

of the University of Dayton. Furthermore, I certify that (s)he has adequate health insurance to cover any injury or

damage that (s)he may suffer while participating, or alternatively, agree to bear all costs associated with any such

injury or damages to her/him.

I, the undersigned, do hereby release, hold harmless, indemnify, waive, and discharge the University of Dayton and

all its officers, agents, and employees from and against any and all claims, demands, actions or causes of action

arising from any injuries or damages my child may suffer or sustain from her/his participation in, or use of, any facility,

equipment, and/or programs. Furthermore, in full recognition and appreciation of the potential dangers and hazards

inherent in athletic and other activities, I do hereby agree to assume any and all risks, liabilities, and responsibilities

for all accidents, injuries, damages, or property losses arising from my child’s participation.

In the event of a medical emergency requiring more than basic first aid, I authorize University of Dayton officials and

Board of Trustees of University of Dayton to secure from any licensed hospital, physician, and/or medical personnel

any treatment deemed necessary for my child’s immediate care and agree that I will be responsible for payment of

any and all medical services rendered.

I have read and fully understand the above statements.

Print Name of Participant Print Name of Parent/Legal Guardian

Signature of Participant Signature of Parent/Legal Guardian

Date Date

B.E.S.T. SUMMER PROGRAM 2015: INFORMATION SHEET

About the Program

The University of Dayton offers an opportunity to high school students to participate in a practical learning

experience in various areas of study. B.E.S.T. focuses on Business, Engineering, Science and Technology, in

which most courses are centered around hands on learning through labs and/or group projects. The program

will run from July 6, 2015 to July 31, 2015, for a period of four weeks.

Academic Components of B.E.S.T.

The B.E.S.T. program allows students to undertake 6 University of Dayton credit hours, which includes:

• 3 credit English/Communication course; and

• 3 credit Engineering course OR

• 3 credit Business course.

Cost

Students will be charged $6,500 program fee, which covers:

• 6 credit hours tuition;

• Room and board;

• Meal plan; and

• Activities.

Students will be responsible for travel expenses and any other miscellaneous expenses (i.e., health insurance,

textbooks) while at the University of Dayton.

Computer Requirements

All UD students are required to have a notebook computer that meets the academic hardware and software

requirements of the University. Students must bring with them to the University of Dayton a laptop meeting our

minimum requirements. For details, please visit

http://www.udayton.edu/udit/computing_printing/student_computer_program.php.

Application/Admission Requirements

The program is open to students who have completed at least their sophomore year of high school. Students

wishing to participate in the B.E.S.T. program must have a cumulative GPA of 3.0 or above and be

recommended for admission into the Program by their home institution.

To apply, students must submit the completed ‘B.E.S.T. 2015 student application’ form, ‘B.E.S.T. 2015 consent

and release’ form (if under the age of 18), and official transcript(s) from their home institution.

Application Deadline

All applications and supporting documents must be submitted to the Office of International Admission no later

than April 15, 2015 to ensure acceptance letters can be sent out in a timely manner. For specific application

submission instructions, please refer to the ‘Application Instructions’ document contained in the application

package.

Name____________________________________________________________________________________________

First Middle Last

Address___________________________________________________________________________________________

__________________________________________________________________________________________________

City State Zip Country

Cell Phone (__________) ______________________ Email_________________________________________________

Date of Birth________/________/________ Age at the time you will enter the University__________

Student ID number (required)_________________________________

First term of Enrollment (circle) Fall Spring Summer I Summer II Year: 20__________

Please circle: Freshman Law/ Grad. Student Transfer International Student Commuter Online Class Only

THIS FORM MUST BE COMPLETED AND SIGNED BY YOUR HEALTH CARE PROVIDER

Required immunizations: This information must be submitted to avoid a medical hold on class registration.

Due July 1 for fall semester, Jan 1 for spring semester.

MMR (Measles, Mumps, Rubella): Two doses required for all students born in 1957 or later.

Dose 1– Given at age 12 months or later. Date of administration_______/________/________

Dose 2– Given at least one month after the rst dose. Date of administration_______/________/________

Exemption: Students born before 1957 are exempt from this requirement. Proof of positive MMR titer results also satisfy the

MMR requirement (attach lab reports).

HEALTH CARE PROVIDER (Signature or stamp required)

Name___________________________________________ Signature________________________________________

(Please print)

Address___________________________________________________________________________________________

Phone (__________) ______________________ Date____________________________________

Student name (print)_____________________________________ Student ID #_______________________________

Meningitis and Hepatitis B vaccines are strongly recommended. The state of Ohio requires that all students who plan to

live on campus disclose whether or not they have been vaccinated against Meningitis and Hepatitis B or sign the vaccine

disclosure statement (below).

Hepatitis B: Dose 1_____/______/_____ Dose 2_____/______/_____ Dose 3_____/______/_____ (required for Doctor of

Physical Therapy students)

Meningococcal vaccine: Menactra____/____/____ Menveo____/____/____ Menomune____/____/____

Declined meningitis or hepatitis B vaccination (student signature required, parent if student is under 18)

I have read the attached CDC guidelines and understand the associated risk of Meningococcal disease and Hepatitis B

disease.

Signature_______________________________________________________ Date_______________________________________

UNIVERSITY OF DAYTON HEALTH REQUIREMENTS

Return completed forms to University of Dayton Gosiger Health Center

300 College Park | Dayton, OH 45469-0900 | Phone: 937-229-3131 | Fax: 937-229-3107

OPTIONAL IMMUNIZATIONS

The following vaccines are strongly recommended, but are not required for admission.

1. Tetanus and Diphtheria (date of most recent): Tdap: ___/___/___ or Td: ___/___/___

(Tdap is required for students who will be working in childcare settings, including some Education students.)

2. HPV (Human Papillomavirus): Dose #1: ___/___/___ Dose #2 : ___/___/___ Dose #3 : ___/___/___

3. Hepatitis A: Dose #1: ___/___/___ Dose #2 : ___/___/___

4. Varicella: Dose #1: ___/___/___ Dose #2 : ___/___/___

5. Other vaccinations (e.g. oral typhoid for travel etc.) ___________________________________________________

TUBERCULOSIS (TB) QUESTIONNAIRE Required for all students (please circle response)

1. Have you had contact with a person with active TB? Yes No

2. Have you ever lived or worked in a nursing home, correctional facility (jail/prison), homeless shelter, hospital, or other

healthcare facility? Yes No

3. Do you have a chronic medical condition or take medication that impairs the immune system? Yes No

4. Have you ever used illegal IV drugs or cocaine? Yes No

5. Were you born in one of the countries listed below, or spent more than 1 month visiting these countries?

(If yes, please circle the country or countries, below) Yes No

Afghanistan

Algeria

Angola

Argentina

Armenia

Azerbaijan

Bahrain

Bangladesh

Belarus

Belize

Benin

Bhutan

Bolivia (Plurinational State

of)

Bosnia and Herzegovina

Botswana

Brazil

Brunei Darussalam

Bulgaria

Burkina Faso

Burundi

Cambodia

Cameroon

Cape Verde

Central African Republic

Chad

China

Colombia

Comoros

Congo

Côte d’Ivoire

Croatia

Democratic People’s

Republic of Korea

Democratic Republic of the

Congo

Djibouti

Dominican Republic

Ecuador

El Salvador

Equatorial Guinea

Eritrea

Estonia

Ethiopia

Fiji

Gabon

Gambia

Georgia

Ghana

Guam

Guatemala

Guinea

Guinea-Bissau

Guyana

Haiti

Honduras

India

Indonesia

Iraq

Japan

Kazakhstan

Kenya

Kiribati

Kuwait

Kyrgyzstan

Lao People’s Democratic

Republic

Latvia

Lesotho

Liberia

Libyan Arab Jamahiriya

Lithuania

Madagascar

Malawi

Malaysia

Maldives

Mali

Marshall Islands

Mauritania

Mauritius

Micronesia (Federated States

of)

Mongolia

Morocco

Mozambique

Myanmar

Namibia

Nepal

Nicaragua

Niger

Nigeria

Pakistan

Palau

Panama

Papua New Guinea

Paraguay

Peru

Philippines

Poland

Portugal

Qatar

Republic of Korea

Republic of Moldova

Romania

Russian Federation

Rwanda

Saint Vincent and the

Grenadines

Sao Tome and Principe

Senegal

Seychelles

Sierra Leone

Singapore

Solomon Islands

Somalia

South Africa

Sri Lanka

Sudan

Suriname

Swaziland

Syrian Arab Republic

Tajikistan

Thailand

The former Yugoslav

Republic of Macedonia

Timor-Leste

Togo

Tunisia

Turkey

Turkmenistan

Tuvalu

Uganda

Ukraine

United Republic of

Tanzania

Uruguay

Uzbekistan

Vanuatu

Venezuela (Bolivarian

Republic of)

Viet Nam

Yemen

Zambia

Zimbabwe

(Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2010. Countries with incidence rates of ≥ 20 cases per

100,000 population. For future updates, refer to http://apps.who.int/ghodata)

IF YOUR ANSWERED YES TO TB QUESTIONS 1-5 OR CIRCLED ONE OR MORE COUNTRIES ABOVE, THE

FOLLOWING INFORMATION IS REQUIRED WITHIN ONE YEAR PRIOR TO ARRIVAL.

Tuberculin Skin Test Date given: _____/_____/_____ Date read: _____/_____/_____

Result: ________mm Negative Positive (Attach results)

or TB blood test (IGRA such as T-spot or Quantiferon Gold) Negative Positive (Attach results)

Chest X-ray result (required if tuberculosis skin or blood test is positive): Date____/____/____ Normal Abnormal

(Attach results)

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