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)