North Carolina A&T State University

College of Engineering

Department of Computer Science

gencyber summer program

For High School Students

Deadline: Completed packages must be received no later than June 8, 2018

Please answer all questions. Type all answers in the grey boxes. Once application is complete, print and complete signatures in ink. Return the completed applicationformand all required attachments by Friday, June 8, 2018 to the Office of Continuing Education, North Carolina AT State University, 1601 E. Market St., Wendover Building Suite 101, Greensboro, NC 27411.For registrationinformation, contact Pat White at (336) 334-7810 or . For program content contact Dr. Xiaohong (Dorothy) Yuan at (336) 285-3693 or .

Please check one session to attend:

Session I: July 16-20, 2018Session II: July 23-27, 2018

Personal Information

Double click in the gray boxes to type

Date of Application

Applicant'sName

CurrentStreet Address

CityStateZip Code Email:

Home Telephone () Cell ()

U.S. Citizen: Yes No

Ethnic Group/Race - (Used for reporting purposes only. Check one.)

American Indian or Alaskan Native Hispanic

Black (Non-Hispanic Origin) Caucasian

Asian or Pacific Islander Other ______

Gender:MaleFemaleT-Shirt Size:

IN CASE OF EMERGENCY CONTACT (NAME):

(Relationship to applicant: father, mother, guardian, etc).

Address:

Home Telephone ()Work Telephone () Cell Telephone ()

Academic Activities

Honors and Awards (check those that apply):

Class Officer Governor's School Who's Who National Honor Society

Girls' or Boys' StateOthers (please list)

Athletics(list activities)

Extra-curricula/Special Talents (list):

Post High School Plans

Areyou interested in applyingfor admission to North Carolina A&T? Yes No

If yes, intended major: First Choice Second Choice

Term of Entry: Fall Semester,Spring Semester,

If you arenot interested in applyingfor admission to North Carolina A&T, please list colleges/universities to which you intend to apply.

How did you learn about the GenCyber Summer Program at North Carolina A&T?

High School Information:This Section to be completed by applicant:

Name of High School

Street Address

CityStateZip Code

Classification:RisingFreshmanRising Sophomore

Rising Junior Rising SeniorExpected Graduation Date(Month Year)

Cumulative GPA

School Telephone Number ()

Indicate the date(s) applicant took or plans to take the following tests and test scores where applicable.

Test / Month/Year / Score / Month/Year / Score
American College Test (ACT)
Scholastic Aptitude Test (SAT)
SAT Achievement Test(s)
Other, Specify______

Applicant's Signature ______

PLEASE NOTE:

The complete application package must include the following:

  • The application form completed by the student
  • Students must be rising 8ththrough 12th grade for the 2018-2019 academic years.
  • A copy of official high school transcript, indicating the student’s GPA.
  • A typed essay “Why do you want to attend the GENCYBER Summer Program, and why can the camp benefit you.”
  • Letter of Recommendation: One letter of recommendation must be included in package. Letters must be typed on official letterhead (notebook paper is not acceptable). One letter must come from a representative from your school (i.e., Career and Technical Education instructor, science, math, or counselor).
  • Student will be notified of acceptance by email on June12, 20018 and will receive an official email.

______

North Carolina A&T State University is committed to equality of educational opportunities and does not discriminate against applicants, students, or employees based on race, color, national origin, religion, sex, age or handicap.

CONSENTFOR MEDICALTREATMENTFORM

For your child to receive medical treatment in the event of illness or injury while participating in the Summer Youth Programs, please provide the following information and sign the consent form below.

Please use one form per child:

Student's Name: Date of Birth:

Parent/Guardian: Address: City/State/Zip:______

InsuranceCompanyPolicyNumber: Name ofPolicyHolder:

Employer:

Physician:Name:

Address:

CityStateZip

Telephone:Fax:Dateoflast Tetanusshot:

Listanymedicalconditionfor whichyourchildis beingtreated:

Listallmedicationsyourchildiscurrentlytaking:

Listallfoodandmedicationallergies:

Listallspecialaccommodations anddietaryrestrictions:

MEDICAL TREATMENT CONSENT:I,(parent/guardian),do herebyconsentandgrantpermissionformychild, , toreceivenecessarymedicaltreatmentintheeventofaninjuryorillnesswhileattendingtheSummerYouthPrograms.Iacceptfullresponsibilityforthepaymentof allsuchmedicalcharges. IherebyindemnifyNorthCarolinaA&TStateUniversity, the StudentHealthCenter,itsemployees and representativesand holdthemharmlessintheexercise of itsdutyunderthisauthority.

SignatureDate

NorthCarolinaA&TStateUniversityPhoto Release

I grantpermission totheOfficeofContinuingEducation,on behalfofNorthCarolinaA&TStateUniversityand itsagents or employees,to use photographstaken ofme on thedateandat thelocationlistedbelow for use inuniversitypublicationssuch as recruitingbrochures,newsletters,andmagazines, and to usethephotographsondisplayboards,andtousesuchphotographsinelectronicversionsofthesamepublicationsoronUniversitywebsitesor otherelectronicformor media,andtoofferthemforuseordistributioninothernon-universitypublications,electronic or otherwise,without notifyingme.

Iherebywaiveanyrighttoinspectorapprovethefinishedphotographsorprintedorelectronicmatterthatmaybe usedinconjunctionwiththemnowor inthefuture,whether that use isknowntome or unknown,and Iwaive anyrighttoroyalties or other compensationarisingfromor relatedtotheuse of thephotograph.

Iherebyagreetorelease,defend,andholdharmlesstheNorthCarolinaA&TBoardofDirectors,onbehalfofNorthCarolinaA&TStateUniversityand itsagents or employees,including anyfirmpublishingand/ordistributingthefinishedproduct inwhole or inpart,whether on paperorviaelectronicmedia,fromandagainstanyclaims,damagesorliabilityarisingfromorrelatedtotheuseofthephotographs,includingbutnotlimitedto anymisuse,distortion,blurring,alteration,opticalillusion oruse incompositeform,eitherintentionallyorotherwise,thatmayoccurorbeproducedintaking,processing,reductionorproductionofthefinishedproduct,itspublication or distribution.

Iam18yearsofageorolderandIamcompetenttocontractinmyownname.Ihavereadthisreleasebeforesigningbelow,andIfullyunderstandthecontents,meaningandimpactofthisrelease.IunderstandthatIamfreetoaddressanyspecificquestionsregardingthisreleasebysubmittingthosequestionsinwritingpriortosigning, and Iagreethat myfailureto do so willbe interpreted asa freeandknowledgeableacceptance oftheterms of thisrelease.

North Carolina A&T StateUniversityCampus– June 16-20, 2018 – July 23-27, 2018

Location ofPhoto/Date(s)

Name(pleaseprint)

Signature

Signature of guardianif under 18 years ofage

1

NorthCarolina Agricultural and Technical StateUniversity Summer Youth Programs

WAIVEROFLIABILITY,ASSUMPTION OFRISKANDINDEMNIFICATION AGREEMENT

Waiver: In consideration ofbeingpermittedtoparticipateinanywayintheSummerYouthProgramshereinaftercalled “Activity”,I, for myself,mychild, myheirs, personalrepresentativesorassigns,do herebyrelease,waive,discharge,andcovenantnottosue NorthCarolinaAgriculturalandTechnicalState University,itsofficers,employees,andagentsfromliabilityfromanyandall claimsresultinginpersonal injury,accidentsorillnesses(includingdeath),andpropertylossarisingfrom, butnotlimited to, mychild'sparticipationintheActivity.

AssumptionofRisks:ParticipationinActivitycarrieswithitcertaininherentrisksthatcannotbeeliminatedregardlessofthecaretakentoavoidinjuries.Thespecificrisksvaryfromoneactivitytoanother,buttherisksrangefrom1)minorinjuriessuchasscratches,bruises,andsprainsto2)majorinjuriessuchaseyeinjuryorlossofsight,jointbackinjuries,heartattacks, andconcussions to3) catastrophicinjuriesincludingparalysisand death.Ihave readthe previousparagraphsandIknow,understand,andappreciatetheseandotherrisksthatareinherentinthesaidActivity. Iherebyassertthatmyparticipationis voluntaryandthatIknowinglyassume allsuchrisks.

Indemnification and HoldHarmless:Ialsoagreeto INDEMNIFY AND HOLDNorthCarolinaAgriculturalandTechnicalStateUniversityHARMLESS fromanyand allclaims,actions,suits,procedures,costs,expenses, damagesandliabilities,includingattorney'sfeesbroughtasaresultofmyinvolvementinActivityandtoreimbursethemforanysuch expensesincurred.

Severability:Theundersignedfurtherexpresslyagreesthattheforegoingwaiverandassumptionofrisksagreementisintendedto be asbroad andinclusive is permitted bythe law ofthestateofNorthCarolinaandthatif anyportionthereof isheldinvalid,it isagreedthatthebalanceshall,notwithstanding,continue infulllegalforce andeffect.

AcknowledgmentofUnderstanding:Ihavereadthiswaiverofliability,assumptionofrisk,andindemnityagreement,fullyunderstanditsterms, andunderstandthatIamgivingup substantialrights,includingmyrightto sue. IacknowledgethatIamsigningtheagreementfreelyandvoluntarily andintendbymysignaturetobeacompleteandunconditionalrelease ofallliability to thegreatestextentallowed bylaw.

EVENTORIENTATION SHEET:

1.In case of medicalemergencies,EmergencyMedicalServiceswillbecontacted. Ifyouwantmedicaltreatmentto be providedtoyourchild,pleasealsosignand returntheConsentforMedicalTreatmentForm.

2.Participantsareexpectedto representthemselves inan appropriatemanner,abide bycampuspolicies,andunderstandthattheywillbe heldaccountablefortheirbehavior.

Ihave read theabove-mentioneddocument,understanditand agree toabide bytherulessetforth.Name ofParticipant ______Date: ______

College of Engineering - Department of Computer Science