ASPIRE application

Please mail or fax completed application by
December 6 to:

Gregory M. Dabkowski, Education Coordinator
Polymer Science and Engineering Department
University of Massachusetts
Amherst, MA 01003

Email: gdabkowski@resgs.umass.edu

Tel: 413-545-0045
Fax: 413-545-0082

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___________________________________________

___________________________________________

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

(Sessions will be held from 8:30 am to 12:30 pm)

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?

______________________________________________________________________________

What do you plan to do after graduation?

______________________________________________________________________________

What hobbies do you enjoy?

______________________________________________________________________________

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:

latex allergies
chemical sensitivities
asthma
pacemakers
metal or artificial joints

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:

______________________________________________________________________________

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
Polymer Science and Engineering Department
University of Massachusetts
Amherst, MA 01003

Email: gdabkowski@resgs.umass.edu

Tel: 413-545-0045
Fax: 413-545-0082