BOOST Application 2016

Student Name:
Current School: / Science Teacher:
Current Grade: / Gender: / Date of Birth: / / /
Middle School where you will be enrolled next year:
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 2ndParent/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 27-July 1, 2016 at Duke for all applicants selected as Scholars. The program runs from 8:30AM to 4:30PM daily and includes breakfast, lunch, and snacks. There is no charge to participate in any BOOST activities.
If selected to be a BOOST XXL Scholar, will this applicant be able to participate in the Summer Immersion Program at Duke June 27-July 12016? / YES NO
Por favor regrese este forma antes de Viernes, 8 de Abril, 2016:
Alexandra Valladares, BOOST Program Assistant
Box 3710, Duke University Medical Center
Durham, NC 27710
Fax: 919-668-3714

Questions for BOOST XXL Applicants

There has been an increase in violence in your school and community. Every day there are more of your neighbors and fellow students behaving aggressively, fighting, disrespecting each other, and vandalizing the community and school. Many students have reported having trouble concentrating, controlling their anger and staying focused. Some have even started having seizures, vomiting, complaining of headaches, coughing uncontrollably and staying home sick.

These things are happening at a time when there are also other strange things happening in the community. Many of the trees are dying, there is brown water coming out of the faucets, there is a strange smell in the air on campus, there has been strange barrels left on empty lots. No one has seen a bird or squirrel in the area for weeks.

President Obama has asked you to assemble a team of experts to look into and solve this mystery. In the space below, please answer each of the following questions.

1. / What experts would you need and why?
2. / How would you coordinate the efforts of your experts? How would you deal with disagreements?
3. / Have you applied to any other summer programs (Student U, SMASS, TIP, FEMMES)? / YES NO
4. / How would you present your findings to the President?
5. / What could be the answer to the strangeness at your school and community?

Questions for BOOST XXL 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?
5. / Why do you want your child to be a part of BOOST XXL?

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