Bridge Program Application

PROGRAM INFORMATION

* Indicates a required field

This application is for a ...

Please indicate by check mark all programs that you are applying for:

2023 Summer Academy (Current 9th-10th graders) - (June 19 – July 14, 2023, Monday - Friday)

2023 Middle School Summer Academy (Current 6th-8th graders) - (June 19 – July 14, 2023, Monday - Friday)

2023-2024 Saturday Academy (Grades 9th-12th) - (Oct 07, 2023 - Mar 02, 2024, First two Saturdays of each month October-February)

PERSONAL INFORMATION

First Name

Middle Name

Last Name

Suffix

Preferred Name

DOB

Current Age

Street Address:

Country

Street

City

Region

Postal Code

Home Phone #

Mobile #

Student Email Address:

Parent Email Address:

Ethnicity

Gender

Male

Female

Other:

Do you have a disability, IEP or receive special accommodations in your school?

Yes

No

Please specify in the box below:

Parent/Guardian #1 First Name:

Parent/Guardian #1 Last Name:

Home Phone #:

Work Phone #:

Parent/Guardian #2 First Name:

Parent/Guardian #2 Last Name:

Home Phone #:

Work Phone #:

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Phone #:

Emergency Mobile #:

Relation To Student:

SCHOOL INFORMATION

School Name

School Type:

Expected grade level for upcoming school year

Provide the year you plan to graduate from High School (enter four-digit year).

For “New” participants only: Your high school counselor, administrator, or instructor must complete a recommendation letter. As the applicant, you must request and upload your recommendation letter by the deadline. Recommendation letters must be on official school letterhead and uploaded as a PDF.

Recommender's Name:

Recommender's Email Address:

Have you taken the ACT?

Please provide your composite score:

Please enter the date in which you took the ACT exam;

Please enter the date in which you plan on taking the ACT exam;

What are your career interests?

Please list your school activities such as: sports, clubs and/or community service projects:

Upon high school graduation, will you be a first generation student? (first to go to college in your immediate family)?

PARENT(S)/GUARDIAN DEMOGRAPHIC INFORMATION

(The below information will assist with proposals for program funding only.)

Please state your parent(s) occupation(s):

Parent/Guardian #1

Parent/Guardian #2

Please state your parent(s) educational level:

Parent/Guardian #1

Parent/Guardian #2

Number of Children in Household:

Number of Adults in Household:

Please check the annual family income below that applies to your family:

Student T-Shirt Size:

Program Referral Source:

Enter a referral source:

Please check the box below for confirmation

I give permission for my child to participate in field trips, lab and classroom activities conducted by the Bridge Program during Academy sessions.

By checking this box, you, the applicant, agree to the terms set by Acceptable Use Policy. You understand that failure to adhere to the terms set may result in denial of access to University information technology resources, and other appropriate disciplinary actions.

I agree to the terms set by this policy

University of Missouri-St. Louis

Bridge Program Application

PARENT(S)/GUARDIAN DEMOGRAPHIC INFORMATION

Academic Units

Administration