Eye on Diversity Application

Eyes on Diversity:  Eye Academy Winter 2022

Get more information on our website UMSL Optometry Eyes on Diversity
 

STUDENT PERSONAL INFORMATION:
Birthdate
Birthdate
Current Address
Current Address
Which group(s) do you consider yourself a member of?
Which group(s) do you consider yourself a member of?
Gender:
Gender:
Guardian Information:
Emergency Contact Information:
School Information:
Grade Level:
Grade Level:
School Location
School Location
School Type:
School Type:
Have you taken the ACT or SAT?
Have you taken the ACT or SAT?
Upon high school graduation, will you be a first generation college student? (first to go to college in your immediate family)
Upon high school graduation, will you be a first generation college student? (first to go to college in your immediate family)
Program Referral Source:
Program Referral Source:
Letter of Recommendation:
Guardian/Parent Agreement:
Parent or Guardian must agree to each of the following:
I give permission for my child to participate in field trips, lab and classroom activities conducted by the Eyes on Diversity program:
I give permission for my child to participate in field trips, lab and classroom activities conducted by the Eyes on Diversity program:
I (parent/guardian) have read and agree to the rules, guidelines, procedures and policies described in the Eyes on Diversity Code of Conduct Contract, Instructional Computing Lab Form, Pre-Clinic Safety Contract, and Science Lab Safety Contract.  
I (parent/guardian) have read and agree to the rules, guidelines, procedures and policies described in the Eyes on Diversity Code of Conduct Contract, Instructional Computing Lab Form, Pre-Clinic Safety Contract, and Science Lab Safety Contract.  
I (parent/guardian) hereby give permission to the Office of Precollegiate Programs and/or UMSL-College of Optometry to use any information we provide and/or photographs in any information or promotional materials they may create to advertise or promote program opportunities, and we waive and release the university from any financial obligation in connection with my services.
I (parent/guardian) hereby give permission to the Office of Precollegiate Programs and/or UMSL-College of Optometry to use any information we provide and/or photographs in any information or promotional materials they may create to advertise or promote program opportunities, and we waive and release the university from any financial obligation in connection with my services.
I, (parent/guardian) acknowledge that my son or daughter is entering into a safety contract to facilitate learning science lab skills in the best possible environment.  All rules set forth by the OPP must be followed by my student during science lab activities to ensure the safety of my student. 
I, (parent/guardian) acknowledge that my son or daughter is entering into a safety contract to facilitate learning science lab skills in the best possible environment.  All rules set forth by the OPP must be followed by my student during science lab activities to ensure the safety of my student. 
Student Agreement:
Student must agree to each of the following:
I (student) have read and agree to the rules, guidelines, procedures and policies described in the Eyes on Diversity Code of Conduct Contract, Instructional Computing Lab Form, Pre-Clinic Safety Contract, and Science Lab Safety Contract.  
I (student) have read and agree to the rules, guidelines, procedures and policies described in the Eyes on Diversity Code of Conduct Contract, Instructional Computing Lab Form, Pre-Clinic Safety Contract, and Science Lab Safety Contract.  
I (student) hereby give permission to the Office of Precollegiate Programs and/or UMSL-College of Optometry to use any information we provide and/or photographs in any information or promotional materials they may create to advertise or promote program opportunities, and we waive and release the university from any financial obligation in connection with my services.
I (student) hereby give permission to the Office of Precollegiate Programs and/or UMSL-College of Optometry to use any information we provide and/or photographs in any information or promotional materials they may create to advertise or promote program opportunities, and we waive and release the university from any financial obligation in connection with my services.
I (student) agree to utilize all campus computing labs for the purpose of completing classroom activities. Access to computing resources is contingent upon prudent and responsible use.  Inappropriate use of computing services and facilities may result in loss of computing privileges.  In addition, disciplinary and/or legal action will be pursued for violation of these codes and statutes through appropriate University procedures. (pending University approval for on-campus meetings)
I (student) agree to utilize all campus computing labs for the purpose of completing classroom activities. Access to computing resources is contingent upon prudent and responsible use.  Inappropriate use of computing services and facilities may result in loss of computing privileges.  In addition, disciplinary and/or legal action will be pursued for violation of these codes and statutes through appropriate University procedures. (pending University approval for on-campus meetings)
I (student) agree to abide by the safety regulations as set forth in the Student Safety Contract and any additional instructions provided by course instructors. I further agree to follow all other written and verbal instructions given during science course virtual seminars and/or lab activities.
I (student) agree to abide by the safety regulations as set forth in the Student Safety Contract and any additional instructions provided by course instructors. I further agree to follow all other written and verbal instructions given during science course virtual seminars and/or lab activities.