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SUMMER GIFTED AND TALENTED PROGRAM
SUMMER 2015 APPLICATION FORM
CONTACT INFORMATION
STUDENT NAME ___________________________________________________ GENDER: □ Male
□ Female
NAME OF PARENT ________________________________________________ STUDENT D.O.B. ____/____/____
MAILING ADDRESS_____________________________________________________________________________
HOME PHONE (____) _____________ CELL PHONE (____) ____________ WORK PHONE (____)____________
EMAIL ADDRESS(ES) ___________________________________________________________________________
EMERGENCY CONTACT INFORMATION
CONTACT NAME _______________________________________________________________________________
RELATIONSHIP (CANNOT BE PRIMARY PARENT ABOVE)___________________________________________
CELL PHONE (_______) _______________________ ALTERNATE PHONE (_______) ______________________
SCHOOL INFORMATION
NAME OF CURRENT SCHOOL ___________________________________________________________________
STREET ADDRESS ______________________________________________________________________________
CITY ________________________________ ST _____ ZIP CODE ________ PHONE (_____)_________________
NAME OF PRINCIPAL OR GIFTED COORDINATOR _________________________________________________
DOES YOUR SCHOOL HAVE A GIFTED PROGRAM? Yes
No
ARE YOU ENROLLED? Yes
No
Identification and/or participation in a gifted/talented program is not a requirement, nor a guarantee, for admission into Dominican University's
Summer Gifted and Talented Program.
STUDENT GRADE LEVEL IN FALL 2015 ______
NAME OF SCHOOL IN FALL 2015 _____________________________________________________________
SUMMER GIFTED AND TALENTED PROGRAM ADMISSIONS CRITERIA:
APPLY AS TEST SCORE OR ADMISSION PORTFOLIO OR RETURNING STUDENT
TEST SCORE STUDENT: Students with nationally-normed standardized test scores in the 90%ile or above in the
subject area to which they are applying are pre-qualified for enrollment, pending course availability and completion of
any listed prerequisites. Must include copy of official score report, or submit school official's signature below to
confirm scores.
ADMISSION PORTFOLIO STUDENT: Students without nationally-normed standardized test scores in the 90%ile
or above may apply by Admission Portfolio. Include 1-2 completed teacher recommendation form(s) that speak to their
academic strength and readiness for the selected course(s) of choice. Download the Teacher Recommendation Form
online. Evaluations from similar G&T program can also be submitted for consideration, as well as current report cards
and student portfolios or writing samples.
RETURNING STUDENT: Returning students have standardized test scores and/or teacher recommendation(s) on file
for relevant subject areas, and have already successfully completed a Summer Gifted and Talented Program course in
the same subject area. Returning students may be requested to provide updated information upon application review.
LIST THE MOST RECENT NATIONALLY-NORMED STANDARDIZED TEST AND TEST DATE BELOW
(including but not limited to ISAT, ITBS, Terra Nova, NWEA, EXPLORE, and/or off-level SAT/ACT):
Name of test(s):_________________________________________________________________________________
TEST SCORE BY PERCENTILE RANK:
MATH
_________
READING/VERBAL
_________
SCIENCE
_________
COMPOSITE
_________
ADDITIONAL STANDARDIZED TEST(S) AND SCORE(S):
INCLUDE A COPY OF THE OFFICIAL SCORE REPORT(S) OR:
PRINT SCHOOL OFFICIAL NAME/TITLE ______________________________________________________
CONTACT NUMBER (______) _____________________ EMAIL ___________________________________
SIGNATURE OF SCHOOL OFFICIAL REQUIRED HERE: ______________________________________
The school official’s signature above confirms that the standardized test scores submitted on this form are accurately documented.
Questions? Email us! [email protected] Call us! 708-524-6525
View or print course descriptions and application forms: educate.dom.edu/academics/gifted-talented
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Student Name: ____________________________________
COURSE SELECTION Circle the course(s) that reflect your demonstrated academic area of strength and interest.
You may number your first and second course choices by week. In the event that select course(s) have filled to
capacity, you will be contacted to select an alternate course if one is applicable and/or join a wait list. Students are
enrolled in one course per week only.
* denotes additional $15 course supply fee
□
Week 1: June 15-June 19 Enrollment Notes:
Grade Band
Math Reasoning
Science Reasoning
Verbal Reasoning
2/3
Fun with Fibonacci!
To Infinity and Beyond!
Calling All Artists*
3/4
Aerodynamics*
Chemical Reactions*
The Almost Neverending Story
4/5
5/6
Math Games, Puzzles & Problems
Forensic Science*
Chess Masters (5-8)*
6/7
Environmental Science (5-7)*
Physics & Engineering (6-8)*
Stock Market Challenge
7/8
□ AND □ OR
Awesome Artistry (4-6)*
Writer’s Workshop (5-7)
Exploring Photojournalism (6-8)*
Week 2: June 22-June 26 Enrollment Notes:
Grade Band
Math Reasoning
Science Reasoning
Verbal Reasoning
2/3
Number Pyramids and Puzzles
The Brain
Ancient Wonders
3/4
Aerodynamics*
Introduction to Zoology
Word Power Challenge
4/5
Mathopoly
All About that Base*
5/6
Architecture: How Buildings Stand*
Invention Convention (5-7)*
Logic & Critical Thinking (6-8)
Physics & Engineering (6-8)*
6/7
Fabulous Fibers (4-6)*
Building Model Behavior (6-8)*
American Literature (6-8)*
7/8
□ AND □ OR
Week 3: July 6-July 10 Enrollment Notes:
Grade Band
Math Reasoning
Science Reasoning
Verbal Reasoning
2/3
Monster Math
Jurassic Journeys
Nutrition Club*
3/4
The Number Devil*
Chemical Reactions*
Etch and Sketch*
4/5
5/6
6/7
7/8
Chess Puzzlers and Challenges
Aerodynamics*
Genius of Geometry (6-8)
Physics & Engineering (6-8)*
Lab Science: Eyes of a Scientist*
Stick to the Script! (4-6)
Best of Roald Dahl*
□ AND □ OR
Scream Machine (5-7)*
Wildlife & Conservation Science (6-8)
The Great Debate (6-8)
Week 4: July 13-July 17 Enrollment Notes:
Grade Band
Math Reasoning
Science Reasoning
Verbal Reasoning
2/3
Fun w/Fibonacci!
Awesome Oceans
Amazing Race Around the World
3/4
Chess Academy *
Applications in Science*
Young Authors Book Club
4/5
2
Science Olympiad*
All the World’s My Stage
5/6
Scratch that Code!*
Hunger Games*
6/7
Pi and the Great Pyramid (6-8)
7/8
Physics & Engineering (6-8)*
Einstein Tests Your Brain
SketchUp Architecture (6-8)*
Advertising Agents (5-7)
Rhetoric: the Art of Persuasion (6-8)
Full tuition payment MUST be submitted with the application; any remaining fees accrued at the time of enrollment, including supply fees,
must be paid within 2 weeks of admissions acceptance in order to maintain enrollment.
Questions? Email us! [email protected] Call us! 708-524-6525
View or print course descriptions and application forms: educate.dom.edu/academics/gifted-talented
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Media Release: My child and I have reviewed the Summer Gifted and Talented Program and understand the
nature of the program, its expectations, admissions criteria, and program policies. We agree to abide by all
program expectations and policies, provided upon enrollment. As a parent/guardian, I grant permission for my
child to participate in the Summer Gifted and Talented Program and any related activities supervised by staff,
including field trips. I grant permission for staff to discuss any relevant matters related to my child’s enrollment
and participation in the program with the contacts listed in this application form. I grant Dominican University the
right to reproduce my child’s image and likeness of the student, his/her family members, or the student's work in
any publication or media form(s). I understand there will be no monetary or profitable claim against Dominican
University for such use. I certify that all statements and admissions materials submitted are accurate and
complete. I understand that deliberate submission of inaccurate, incomplete and misleading information, including
the deliberate omission of accurate and complete information, constitutes grounds for program denial or
withdrawal with no refund.
______________________________________________
Parent Signature
_______________________________
Date
Carpool Information: By joining the carpool directory, you agree to provide your mailing address and contact
information to other enrolled families who wish to arrange carpooling. Only those who select the box below, or
submit a written request to join the carpool directory, will be given access to directory information. By checking
the box below, you agree to NOT reproduce the directory for any use beyond Summer Gifted and Talented
Program carpool purposes. You assume all responsibility in carpool arrangements once the directory is received.
▫ Please enroll me in the carpool directory
Medical Information: I, ________________________________________, acknowledge that the Summer
Print Parent First and Last Name
Gifted and Talented Program does not have a registered nurse or health official on staff, and that in the event of a
medical emergency, Dominican University has my permission to act in loco parentis and call an ambulance in a
medical emergency, and/or take my child to the nearest available physician or hospital at my expense. I/my ER
contact will be notified in the event of an ER.
______________________________________________
Parent Signature
_______________________________
Date
Please list any pertinent academic and medical information, including IEPs, learning disabilities, and
allergies (including all food allergies), medications (including EpiPen and asthma inhaler), and relevant details
below, or attach a separate sheet. Details are confidential and limited to pertinent staff on a need-to-know basis
only.
Questions? Email us! [email protected] Call us! 708-524-6525
View or print course descriptions and application forms: educate.dom.edu/academics/gifted-talented
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All enrolled students receive either a Program T-Shirt or a Program Tote Bag (check one)
I would like to receive a:
▫Program T-Shirt (select size below)
▫Kid S _____ ▫Adult S _____ ▫Adult XL _____
▫Kid M _____ ▫Adult M _____
▫Kid L _____ ▫Adult L _____
OR
▫ Program Tote Bag
I would like to order additional: ▫Program T-shirt(s) at $6.00ea ▫Program Tote Bag(s) at $6.00ea ____ qty
Please submit separate check for your additional t-shirt/tote bag order
▫Kid S _____ ▫Adult S _____ ▫Adult XL _____
▫Kid M _____ ▫Adult M _____ ▫Adult XXL _____
▫Kid L _____ ▫Adult L _____ ▫Adult XXXL _____
I would like to contribute a monetary donation to the Summer Gifted and Talented Program to support
program initiatives, special activities, and financial aid funds in the amount of $ ___________.*
(Please submit as separate check)*
Receiving Program Information
All program information will be sent electronically, unless otherwise specified:
▫ Please send paper copy by postal mail
Cut and Save for your reference!
Tuition
▫ Application fee is $25 per student
▫ Tuition is $225 per course per week, plus any applicable supply fees
▫ Tuition for all four weeks is only $800 total (apply early, classes can fill quickly)
▫ A $25 late fee applies to applications submitted after June 5, 2015
▫ Full tuition payment and application fee MUST accompany registration form for admissions consideration; any
outstanding supply fees MUST be submitted within 2 weeks of acceptance
▫ All checks or money orders should be made payable to Dominican University
▫ An admissions letter will be emailed after the student's application has been considered
▫ Faxed, scanned, or emailed application forms are NOT accepted.
Refund Policy
▫ Full tuition refunds will be granted if a written request is received by June 5, 2015
▫ A cancellation fee of $50 will be applied to your tuition refund after June 5, 2015
▫ No refunds will be granted for partial participation or absences
Application Check List:
▫ Completed Application Form
▫ Copy of nationally-normed standardized test scores, and/or school official's signature and contact info
▫ 1-2 Teacher Recommendation Form(s) and report card if standardized test scores at 90%ile or above are not available
▫ Did you double check your course selections? If it's unclear, include enrollment notes detailing your ranked course choices
▫ Did you check to participate in the Carpool Directory?
▫ Did you select your T-shirt size or request a Tote Bag?
▫ Did you make checks payable to Dominican University? Separate your check payments for (1) Tuition fee; (2) Application
fee; (3) Additional course supply fee and/or Additional t-shirt/tote bag fee; (4) Program Donation
▫ Did you include additional course supply fees in your tuition check as it applies?
Mail Application Materials to:
Dominican University School of Education
Summer Gifted and Talented Program
7900 W Division Street
River Forest, IL 60305
Questions? Email us! [email protected] Call us! 708-524-6525
View or print course descriptions and application forms: educate.dom.edu/academics/gifted-talented
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