Application for Summer Leadership Training Course

Privacy Act Statement:  Under authority of title 10, USC 2101, the following information is needed to prepare you for the Summer Leadership Internship.  Completion of this form is voluntary.  Not completing this form will prevent us from processing your application and may disqualify you from enrolling in the program.  Information will be used for the Summer internship program only.

Personal Information

Last Name: ___________________________
First Name:___________________________
M.I._____ SSN________________

Race/Ethnicity: __________________________
Date of Birth:________________ Sex: ___

 Local
Address, City, State, Zip. ___________________________________________________

Permanent/Next of Kin
Address, City, State, Zip. ___________________________________________________

Marital Status: _______________
Next of Kin:________________
Relationship: ___________________________

Local Telephone __________________
E-mail________________________

Permanent Telephone: ______________________
Cellular Phone: _____________________

Are you a US Citizen? ____

Academic Information

School: ______________________
Graduation Date:______________________
Completed Hours______________________

Major______________________
GPA: _____
Are you a veteran? ____
Are you interested in a 2-year scholarship? ________

Medical Information

Are you in overall good health?_________

List any medical condition that could disqualify you from participating in a college physical education course (Asthma, heart trouble, etc.):

Describe any Surgeries you have had:

Requested Cycle: Prioritize the cycle dates by placing a number next to the cycle would most like to attend. All dates are tentative.

• 1st Cycle _____ 8 June 2004 - 5 July 2004
• 2nd Cycle _____ 12 June 2004 - 7 July 2004
• 3rd Cycle _____ 18 June 2004 - 17 July 2004
• 4th Cycle _____ 24 June 2004 - 19 July 2004
• 5th Cycle _____ 27 June 2004 - 23 July 2004

Fax, email or mail to: