View Print Application - Lindenwood University
LINDENWOOD CRIMINAL JUSTICE SUMMER INSTITUTE JUNE 8, 9, and 10, 2015 Student Name (Last, First, Middle Initial):_____________________________________________________ Mailing Address:____________________________________________________________________________________ City, State, Zip:_______________________________________________________________________________________ Name of Parent/Guardian:________________________________________________________________________ Email address (please provide preferred the email address where you prefer CJSI information be sent:______________________________________________________________________________________ Parent/Guardian Phone Number:____________________ (best number to contact) Alternative parent phone ____________ Other emergency contact: Name _________________ Relationship____________________________________ Best contact number: T-shirt size (circle size): Adult Extra Small Adult Small Adult Medium Adult Large Adult Extra-Large Adult XXL Name of high school ______________________________ High school grade in 2014-2015 school year: ____ Freshman ____ Junior ____ Sophomore ____ Senior Participant is considering a criminal justice career in: Juvenile justice Probation and parole Forensic psychology Law enforcement Crime Scene Investigations Corrections Other (specify) Unsure Not considering CJ, just interested in the topic Will your child be bringing any type of medicine to this event? If yes, give type and instructions Yes No __________________________________________________________________________________________________ Does your child have any allergies? Yes No If yes, explain LINDENWOOD CRIMINAL JUSTICE SUMMER INSTITUTE JUNE 8, 9, and 10, 2015 _____________________________________________________________________________________________________ Does your child have special needs (medical, physical or mental challenges) officials should be aware of in making this program safe and accessible for your child? If yes, explain ______________________________________________________________________________________________ If yes, explain _____________________________________________________________________________ (An additional medical form will be required if participant stays in the dorm). Participating students are not permitted to leave campus while participating in the program, unless otherwise required for participation, without a note from parent/guardian. Parent/Guardian: I read the guidelines and rules and I approve of my child’s enrollment in the program. I also understand that if my son or daughter does not follow the guidelines and rules established for the program, he or she may be dismissed from the program without refund. I do ____ do not _____ give permission for my child to be photographed, interviewed, and/or have a sample of his or her work published. Some photographs of student activities and class work may appear on the program’s web page in order to promote CJSI in the future. I understand that the CJSI will exercise discretion regarding media contact. In addition, I agree to permit my child to complete all surveys that the CJSI deems necessary in evaluating program effectiveness. Payment: CJSI day/lunch only: $175.00 _____ CJSI + two nights lodging/meals: $275.00___ Interested in college credit: _________ (Additional $200.00 for two hours of credit/separate payment required; student must have completed sophomore year to be eligible to receive credit) Make check payable to: Lindenwood University Send application and payment to: Lindenwood University c/o of Jeanie Thies, Criminal Justice Department 209 South Kingshighway St. Charles, MO 63301 Or pay online at: http://luspiritshoppe.com/CJSI.aspx (separate check and enrollment form required for college credit hours)
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