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Application Form
Please Print
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Student's Name (Last, First, Initial) Social Security No. Present Grade Level
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Date of Birth School Sex (M) (F) (circle one)
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Parent or Guardian
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Street Address City Zip
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Home Telephone Business Phone
Course Selection: Please check your selection below:
_____ The Arts in an Urban Landscape _____ Science for Enriching Urban Lifestyle
_____ Stepping into Space in the Twenty-First Century _____ Theatre Perfomance
_____ African Music _____Creative Writing
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Emergency Medical Authorization
In the event that reasonable
attempts to contact parents at the following phone numbers have been unsuccessful, I hereby give my consent for the administration of emergency
medical treatment deemed necessary by any licensed physician or dentist. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Home Telephone Number ___________________ ________________________
Parent/Guardian Signature
Mother's Work Number ______________________ ________________________
Address
Father's Work Number __________________________
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Blanket Permission Form Mail Completed Forms To:
__________________________________ Dr. Michael Sanders
has my permission to participate in and attend all Cleveland State University
activities and field trips authorized to be a part of the College of Education
Urban Odyssey. Cleveland, Ohio 44115
(216) 687-4583
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Parent/Guardian Signature
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