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Application for a

Collegium

Summer Week 2024

14-19 July, 2024

YOUR INFORMATION

Name

Address

Email (to verify)

Home Phone

Mobil Phone

Birth date

YYYY

Gender

Male

Female

_______________________________

YOUR FAMILY INFORMATION

Parent/Guardian Name

Second Parent/Guardian Name

Primary Parent/Guardian Address (only if different from yours)

Parent/Guardian Email

Parent/Guadian Email (to verify)

Parent/Gaurdian Phone

_______________________________

YOUR STUDIES

Current School
(If you are currently out of school, check the box that corresponds to your last school attended.)

Homeschool (with or without some online/in-person courses)

Full-time High School (in-person or online)

If your current school choice is Full-time High School:

High School Name

High School Code

High School Location

Is your high school in person or online?

In person

Online

When will you graduate from high school?

YYYY

_______________________________

HEALTH INFORMATION

Do have any physical, medical, or psychological conditions that require special attention?

Yes

If yes, please explain in detail, so we can serve you properly.

Have you consulted or been treated by physicians, clinics or other medical practitioners within the last two years (other than routine checkups)?

Yes

If yes, please explain in detail, so we can serve you properly.

Have you been treated by a psychologist or other mental health practitioner for any mental, emotional, or nervous disorder within the last two years?

Yes

If yes, please explain in detail, so we can serve you properly.

Do you have any dietary restrictions?

Yes

IF yes, please explain in detail, so we can serve you properly.

_______________________________

TRANSPORATION INFORMATION

How will you arrive?

Flying into Dulles (IAD)

Flying into Baltimore (BWI)

Flying into Reagan (DCA)

Driving

If flying, what time does your flight arrive on Sunday?

If flying, what time does your flight depart on Saturday?

_______________________________

TESTIMONY

I hereby certify that the information I provided and answers I have made above are true, correct, and complete to the best of my knowledge. I understand that I am responsible for updating this form with any changes and that failure to provide full, accurate personal information, especially information that might impact one’s personal safety and/or well being, during any portion of the Summer Week may result in my dismissal from the Summer Week.

Yes

I understand that if I am accepted into The Collegium Summer Week, I must sign and follow all rules and regulations.

Yes

I understand that The Collegium is a no-smoking/no vaping environment: that there is no smoking or vaping in any of the facilities leased or operated by The Colllegium.

Yes

Student Signature

Signature

_______________________________

RELEASE OF INFORMATION

The undersigned hereby consent to release to The Collegium the information contained in the undersigned student’s medical history forms and physician’s reports, with the understanding that these files be kept confidential.

Signature of Parent or Guardian

______________________________

MEDICAL RELEASE

In case of medical need, the Director of Admissions, Summer Week Coordinator, Counselor, Faculty Member, or other Collegium employee have the permission of the undersigned to admit the undersigned student to the hospital or to contract with a physician for diagnosis and/or treatment. The undersigned assume, jointly and severally, full financial responsibility for such diagnosis and/or medical treatment and to indemnify The Collegium, its agents and employees against all such claims. I hereby certify that my student has no medical or other health conditions which will prevent their normal and expected participation in the Summer Week. I further certify that my student has sufficient health, accident, and liability insurance to cover any bodily injury or property damage they may incur while participating in the Summer Week and to cover bodily injury and property damage caused to a third party as a result of their participation in this program. In case of emergency, I can be reached at the cell number given below my signature.

Signature of Parent or Guardian

Cell phone for emergency contact:

______________________________

PAYMENT

The fee for Summer Week is $550. This is all-inclusive: tuition, room, board, books, fees.

______________________________

Price

USD

Shipping Fee

Payment Method

Stripe

Stripe Checkout

By clicking on the button above, you will submit the info above and you will be redirected to a secure payment page.