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Please mail or fax completed application by Gregory M. Dabkowski, Education Coordinator
Email: gdabkowski@resgs.umass.edu Tel: 413-545-0045
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ASPIRE Program Application
Program Dates: January 10, 17, 24, 31 & February 7 (with February 14 as a Snow Date)
Applicant must be recommended by a local high school science teacher
Name___________________________________________
Address___________________________________________
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Email address________________________________ Phone Number__________
School Name___________________________________________
Year in school___________
Teacher's Name___________________________________________
Teacher's Signature ___________________________________________
| Are you able to participate in laboratory exercises on Saturdays? | YES | NO |
Are you interested in chemistry? |
YES | NO |
Have you studied chemistry? |
YES | NO |
Are you interested in physics? |
YES | NO |
Have you studied physics? |
YES | NO |
Are you interested in engineering? |
YES | NO |
Do you enjoy learning about science and conducting experiments? |
YES | NO |
Why are you interested in the aspire program?
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What do you plan to do after graduation?
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What hobbies do you enjoy?
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Please have following information completed by your parent or guardian.
Student's Name : ________________________________________________________
In the event of an emergency notify:
Name : __________________________________ Relationship: __________________
Address : ________________________________ Phone : ______________________
The safety of your child is important to us, and in this course the student will be exploring many aspects of polymer science. These include the use of chemicals in the laboratory, use of instrumentation with high magnetic fields and the use of latex gloves. There will be a formal safety training session on safety in the laboratory, but we need to know of any potential health problems that could arise.
We would appreciate if you would let us know of any possible health conditions your child has, such as:
We need to know about any pre-existing conditions, so we can accommodate for your child's needs. Please use the space below to tell us about any existing health conditions from the list above, and any other medical concerns you may have:
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In the event of emergency, where I cannot be reached, I hereby give permission to the physician selected by the adult leader in charge to hospitalize and secure necessary medical attention for my child.
Parent or Guardian Signature : ________________________________________ Date : _______________
If you have any questions, concerns or comments, please feel free to contact us:
| Gregory M. Dabkowski, Education Coordinator
Email: gdabkowski@resgs.umass.edu Tel: 413-545-0045
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