Esteem Research Mentoring Program Application, University of Maryland

ESTEEM Research Mentoring Program
Parent Data Form 2009
Deadline: March 30, 2009

Father or Male Guardian Info

Last Name:	First Name:	MI:
Address:
City:	State:	Zip:
Home Phone:	Work Phone:
Occupation:	Employer:

Mother or Female Guardian Info

Last Name:	First Name:	MI:
Address:
City:	State:	Zip:
Home Phone:	Work Phone:
Occupation:	Employer:

Parental Consent

I understand that is being considered for the ESTEEM Research
Mentoring Program a the University of Maryland College Park. The summer component
June 22—July 2, 2009 and for the academic year component September 14, 2009-May 14, 2010.

I give permission for my daughter/son to participate in the ESTEEM Research Mentoring Program and all related activities if chosen;
I approve of the release of my child’s high school transcript; and will complete a “health questionnaire, if my child is selected as a program participant;
I guarantee my child’s participation for the entire duration of the program (in the event she/he cannot fulfill this commitment, I understand that her/his position in the ESTEEM Research Mentoring Program will terminate immediately).

Emergency Contact:		Relationship:
Emergency Contact Email:		Emerg. Phone:

I certify that as the student’s parent/guardian that I am aware that the student is applying for this program and that she/he has my consent to participate in the ESTEEM Research Mentoring Program should they be selected to participate.

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