High School College Access Program Application

Complete all fields on the attached Program Application and print. Both you and a parent or legal guardian must sign the application. Make sure that the email address you submit in the Student Email field is valid and is the email address you check on a regular basis. We communicate with all applicants via email. In addition to your Program Application, you must also submit the following:

Personal Statement: Please type a one-page statement addressing how you believe enrolling in a college course will benefit you as a high school student. Official High School Transcript, in sealed envelope Copy of your Standardized Test Scores: We will accept PSAT, SAT, ACT, or PLAN scores only. If you do not have standardized test scores then you must submit a letter of recommendation from a teacher. Optional: A letter of recommendation from a teacher or counselor is strongly encouraged, but not required. $35 Application Fee, payable to Washington University

All application materials must be mailed together in one envelope and received by the application deadline. Be sure to keep a copy of your application materials for your records. Send your complete application packet to: High School College Access Washington University in St. Louis Campus Box 1145, January Hall 100 1 Brookings Drive St. Louis, MO 63130-4899 Important Dates & Deadline
Fall 2013 Application Deadline: August 15 First day of classes: August 27 Spring 2014 Application Deadline: January 1 First day of classes: January 13 Summer 2014 Application Deadline: June 1 First day of classes: varies by session

Do you have questions about applying? Contact Becki (Zurovec) Baker at zurovec@wustl.edu or (314) 935-4807

High School College Access Application

type or print clearly

Student Name: ____________________________________________________________________________

last first prefer to be called

Male

Female

Permanent mailing address: ______________________________________________________________________________________

number and street

_____________________________________________________________________________________________________________
city state zip country (if not US)

Home phone: ( Student cell phone: (

) _________________________________ ) ________________________________

Date of birth: ____________________________________

month/date/year

Country of citizenship: ___________________________ Is English your native language? Yes No

Student email address: _______________________________________________ High School: ________________________________________________________

name

______________________________________
city, state

High School Graduation: ________________

year

Public

Private

Boarding )__________________________

Counselors name:_____________________________________________ Cumulative GPA: ____________________ weighted unweighted

Telephone: (

PLAN/ACT: English: ______ Math: _______ Reading: _______ Science: ______ Composite: _______ Year of exam: ________ PSAT/SAT: Critical Reading: _________ Math: ________ Writing: _________ International Students Only: TOEFL Score: _________________ Composite: __________ Year of exam: _______

IELTS Score: ___________________

Activities and interests: In order of importance to you, please indicate no more than three extracurricular activities (community, personal, research, religious, school, athletic, etc.) you have been involved in during high school. ________________________________ ___________________________________ Fall Spring ____________________________________ Summer Year: ___________

The semester in which I would like to begin College Access is: The course(s) I am interested in enrolling: ________________________________

___________________________________

____________________________________

Signature: I certify that the information contained herein is true, complete, and correct. I understand that all materials pertaining to my acceptance become the property of Washington University. Signature of applicant:__________________________________________________ Date:___________________

Part 2 of Application High School College Access

type or print clearly Parent/Legal Guardian Information: Name: _______________________________________________________________________________________________
last first

___________________________________________
email address

(____________)________________________________________
phone number

Liability Waiver & Release

In consideration for my childs voluntary participation in the educational experience provided by Washington University (University) described below, I, the undersigned, on behalf of my child and myself, agree as follows: Permission: I grant permission for my child (print childs full name) to participate in High School College Access (Program), including travel and field trips, offered by Washington University. I understand that some of these activities may include bus, light rail, or automobile transportation, and give permission for my child to be transported as necessary. Assumption of Risks: I am fully aware that the Program, and its activities, involves foreseeable and unforeseeable risks and hazards. I am voluntarily allowing my child to participate in the Program and its activities. I further understand that the University, including the individuals acting on its behalf, cannot and do not assume responsibility for such events or personal injuries or property damage arising there from. I, on behalf of my child and myself, voluntarily assume responsibility for any risks of property damage or personal injury, including death, that my child may suffer as a result of my child participating in the Program and its activities or while traveling to and from Program locations and sites; and further I, on behalf of my child and myself, hereby release, and forever discharge Washington University and its respective staff, officers, agents, employees, volunteers, representatives, successors and assigns (Released Parties) of and from all rights and claims for damages, injury, or loss to person or property (Claims) resulting from my childs participation in the Program whether or not damages, injury, or loss is due to negligence or fault of the Released Parties. Indemnification: I agree to indemnify and defend the Released Parties against, and hold harmless from, any and all Claims, including attorneys fees, which in any way arise from my childs participation in the Program, including any liability arising from the act or negligent act of the Released Parties, my child, or anyone else. University/Program Rules & Regulations: I understand that my child will be subject to the rules and regulations of the University, the Program, and University Residential Housing. Media Release: I grant permission for my child to be photographed or videotaped for purposes of publicity. I understand that some photographs or videos may appear in local newspapers, on future brochures or on the University website and social media. I understand that neither I nor my child will receive monetary compensation in exchange for use of products that include my childs image. Acknowledgement: I certify that I am the parent or legal guardian of the above-named child, that I have read this document, and that I am relying wholly upon my own judgment about the risk of injury to my child by my childs participation in the Program. I am over the age of 18 and am voluntarily signing this agreement as my own free act fully intending to be legally bound by it.
______________________________ Printed name of parent or guardian ______________________________ Signature of parent or guardian _____________ Date