Website: ces.uvi.edu Phone: (340) 693-1080 Email: ces.uvi.edu@gmail.com
Website: ces.uvi.edu Phone: (340) 693-1080 Email: ces.uvi.edu@gmail.com Agriculture Enrichment Summer Camp at UVI Cooperative Extension Service Participant Application 2016 Camp Dates: June 27 to July 22, 2016 Name: __________________________ Gender: ___ Social Security #:_____________________ Date of Birth: ___________________ Age: ____ Today’s Date: __________________________ Home Address: __________________________ Mailing Address: ________________________ City: ________________ Zip: ________ City: __________________ Zip: _________________ Telephone No.: (Home) _______________________ (Cell) _____________________________ Email: ________________________________________________________________________ Person to notify in case of emergency: Name: _________________________ Relationship: ______________ Phone #: _____________ Ethnicity: Black - not Hispanic Hispanic Asian White - not Hispanic American Indian Decline to Answer Education Status: Highest Grade Completed _____ Other Summer or Training Programs Completed:______________________________________ Disability/Disabilit …
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Website: ces.uvi.edu Phone: (340) 693-1080 Email: ces.uvi.edu@gmail.com Agriculture Enrichment Summer Camp at UVI Cooperative Extension Service Participant Application 2016 Camp Dates: June 27 to July 22, 2016 Name: __________________________ Gender: ___ Social Security #:_____________________ Date of Birth: ___________________ Age: ____ Today’s Date: __________________________ Home Address: __________________________ Mailing Address: ________________________ City: ________________ Zip: ________ City: __________________ Zip: _________________ Telephone No.: (Home) _______________________ (Cell) _____________________________ Email: ________________________________________________________________________ Person to notify in case of emergency: Name: _________________________ Relationship: ______________ Phone #: _____________ Ethnicity: Black - not Hispanic Hispanic Asian White - not Hispanic American Indian Decline to Answer Education Status: Highest Grade Completed _____ Other Summer or Training Programs Completed:______________________________________ Disability/Disabilities: (Please leave blank if you have no disability) Primary: __________________________ Secondary: __________________________________ Strengths: _____________________________________________________________________ Weaknesses: ___________________________________________________________________ Means of Transportation: Bus/Safari: ___ Vitran Plus: ___ Drive Self: ____ Driven: ________ By signing below, I certify that the information provided is true to the best of my knowledge. I am also aware that the information I have provided is subject to review and verification and that I may have to provide documents to support this application. Participant’s Signature: _______________________________________ Date: _____________ Parent’s/Guardian’s Signature: _________________________________ Date: ______________ SIGN SIGN