UR-CATS: Undergraduate Research Center for Analytics, Talent, & Success
Success In STEM (SIS) Program
3-Week STEM Prep Program from July 25 - August 12, 2020
Section I
Student Name:
Student ID #:
Address:
City: State:
Zip Code:
Email Address:
Phone:
School Name:
Current HS GPA:
□Male Female
Parent/Guardian Name: Relationship to Student:
Is student the first family generation to attend college?
Day Phone:
Cell Phone:
Email Address:
Emergency Contact Name & Phone:
Relationship to Student:
Please list any STEM related extracurricular activities you currently participate in:
Applications due to Dr. Kevin Shuman (kevin.shuman2@wesley.edu) or Melanie Pritchett
(melanie.pritchett@wesley.edu) by July 5, 2020.
Funded in part by:
NOTE: Program funding is contingent on the
above referenced federal pr
ograms!!
Section II
Please answer the following questions:
What is your career interest?
How did you hear about this program?
Have you previously volunteered/held a leadership role in any STEM clubs/organizations?
(please describe here)
Section III
Please briefly describe the learning outcomes you hope to achieve upon successful completion of the
3 week summer STEM Prep Program:
Any questions or comments please send to STEM Programs Coordinator, Melanie Pritchett at
melanie.pritchett@wesley.edu
Parental Consent Form
I
g
ive my student, , consent to participate in all
(Please Print Student First and Last Name)
Wesley College UR-CATS STEM programs and activities in relation to the 3 week summer STEM
Prep Program and other Wesley College UR-CATS Educational Programs.
Photo/Media Release Consent
Please check one of the following:
I hereby grant the Wesley College UR-CATS STEM Programs’ team permission to feature my
student in any and all photographs and videos published on college public relations mediums,
including (but not limited to) the college website and STEM UR-CATS social media platforms
without payment or any other considerations.
I understand and agree that these materials will become the property of Wesley College
and the STEM UR-CATS program and will not be returned.
I hereby, irrevocably authorize Wesley College and all its entities to edit, alter, copy,
exhibit, publish, and/or distribute all photos and videos for purposes of publicizing the
Wesley UR-CATS STEM programs for any lawful purpose. In addition, I waive the right
to inspect or approve the finished product, including written or electronic copy, wherein
my student is featured. Additionally, I waive any right to royalties or other compensation
arising or related to the use of any photographs and/or videos.
I hereby release and forever discharge Wesley College and all its entities from all claims,
demands, and/or conflicting causes of action.
I hereby
do not
grant Wesley College and all its entities permission to feature my student in
photographs and/or videos in any of its publications, including website entries and social
media posts, without payment or other considerations.
Parent/Guardian (Please Print) Relationship to Student
Parent/Guardian Signature
Date
click to sign
signature
click to edit
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