Career Development
SOWELA STEM iCamp
APPLICATION FORM FOR the SOWELA STEM iCAMP SPONSORED BY SHELL
Student Name: ________________________________ ________________________________ ________
Last First Middle
________________________________ ___________________
________________________________ ___________________
Parish
Are you a US citizen?
• Yes • No Visa Status?
________________________________ ____________________
City State Zip Code
Student: (Home #) ______________________________
(Cell #) ________________________________
(Email) ________________________________
Emergency Contact:________________________________ ___
Relationship:________________________________ _________
Emergency Phone #: ________________________________ __
Circle Last Grade Completed:
5 6 7
• FOOD ALLERGIES • MEDICATIONS • None
Please l ist any food allergies, dietary restrictions, and/or
medications we should be aware of in regards to the student:
________________________________ ____________________
________________________________ ____________________________
________________________________ ____________________________
________________________________ ____________________________
Please list only the individuals (full names) who will have
permission to collect the student from campus:
________________________________ ____________________
________________________________ ___________________
________________________________ ___________________
Parent/Guardian: Driver’s License #: ________________________________ __________________________ State: __________
Circle the student’s t-shirt size. Youth: S M L XL Adult: S M L XL XXL XXXL
EQUAL OPPORTUNITY STATEMENT
This is an equal opportunity school and is dedicated to a policy of non-discrimination in employment or training. Qualified students,
applicants, or employees will not be excluded from any course or activity because of age, race, creed, color, sex religion, national origin, or
qualified handicap. All students have equal rights to counseling and training.
Please complete the following information. This information is required by the state for statistical reports.
RACE: CHECK ONE
SEX: [
] MALE [ ] F EMALE
[ ] 1. AMERICAN INDIAN / ALASKAN
[ ] 2. ASIAN / PACIFIC ISLANDER
DATE OF BIRTH:
[ ] 3. BLACK, NON-HISPANIC
[ ] 4. HISPANIC
__________/__________/__________
[ ] 5. WHITE, NON-HISPANIC
Signature of Parent/Guardian
SOWELA Technical Community College does not discriminate on the basis of race, color, national origin, gender, disability, or age in its programs and
activities. The following person has been designated to handle inquiries regarding non-discrimination policies: Compliance Officer - 3820 Sen J Bennett
Johnston Ave, Lake Charles, LA 70615; 337-421-6565 or 800-256-0483; complianceofficer@sowela.edu
For SOWELA TECHNICAL COMMUNITY COLLEGE office use only:
CLASS TITLE: SOWELA STEM iCamp REGISTRATION: $ N/A
DATE OF CLASS: July 30-Aug. 3, 2018 TIME: PARKING: $ N/A
BUILDING: ROOM
: SGA: $ N/A
INSTRUCTOR: TOTAL DUE: $ N/A
APPROVED BY: ______________________________________________________
