Duke BOOST XL Application 2017

Student Name:
Current School: / Science Teacher:
Current Grade: / Gender: / Date of Birth: / / /
Mailing Address: / Apt.#
City: / State: / Zip Code:
Email Address:
Home Phone: / () - / Cell: / () - / Other: / () -
Name of 1st Parent/Legal Guardian:
Home Phone: / () - / Cell: / () - / Work: / () -
Name of 2nd Parent/Legal Guardian:
Home Phone: / () - / Cell: / () - / Work: / () -
My child has permission to attend field trips, lab visits and other trips sponsored by BOOST
BOOST has permission to photograph my child for use in publicity purposes
I authorize BOOST to transport my child or authorize transportation for my child to a medical facility to be treated in the event of an emergency
I give permission for BOOST to collect my child's report card and EOC testing scores. I understand this information will be used only for program evaluation purposes and be kept confidential.
By signing below, I grant permission for my child, if selected, to be enrolled in BOOST.
My signature confirms that the information provided is accurate.
Parent/Guardian Signature: / Date: / /
To begin the year, BOOST’s Summer Immersion Program will be held the week of June 26th-June 30th, 2017 at Duke for all applicants selected as Scholars. The program runs from 8:30AM to 5:00PM daily and includes breakfast, lunch, and snacks. There is no charge to participate in any BOOST activities.
If selected to be a BOOST XL Scholar, will this applicant be able to participate in the Summer Immersion Program at Duke June 26th-June 30th, 2017? / YES NO
Please return this form by Friday, April 21, 2017:
Alexandra Valladares, BOOST Program Assistant
Box 3710, Duke University Medical Center
Durham, NC 27710
Fax: 919-668-3714

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Questions for BOOST XL Applicants

1. / What was the most challenging part about the transition from 5th grade to 6th grade? In what ways could you say you’ve grown? In what ways do you wish to grow, having experienced a year of middle school?
2. / You’ve just been awarded a grant to conduct a scientific research project. Describe your ideal project, and your plan of action (field of science, materials, experimental procedure, etc.). Why did you choose this project?
3. / Please draw a picture of a possible device to do one of the following things (you may also use the back if needed):
a. / make a sandwich for you
b. / sort skittles according to their color
c. / alter levels of gravity

Questions for BOOST XL Parents

1. / What do you feel are your child’s greatest strengths?
2. / In what areas would you like to see your child grow?
3. / Has your child applied to any other summer programs (ex. SENSOR, SMASS, FEMMES)? / YES NO
4. / What extra-curricular activities is your child involved in (e.g. sports, band, etc.)?
5. / Why do you want your child to be a part of BOOST XL?

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