APPLICATION

Duke University Summer Academy for High Schoo Students SU!!"# $%&'
Application to be completed by: U.S. & International Students: Current grades 9 -12 high school students

A(( ication must )e ty(ed *not hand+ritten,- P ease (rint the a(( ication and sign the Partici(ant Agreement as directed- .hi e you may scan and emai the teacher recommendation/ transcri(t/ essay/ resume or score re(orts/ you may NOT return this a(( ication via emai as a scanned document as it contains sensitive informationReturn completed application with nonrefundable application fee to: Duke Summer Session The Bishops House ttention !r. "ic#i Charles Bo$ 9%&%% !urha'( "C 2&&%)-%&%%

Supporting documentation may be faxed, mailed, or scanned and emailed to: nic#i.charles*du#e.edu The application may only be faxed or mailed. The a(( ication fee of 01%-%% for U-S- students and Internationa students is (aya) e )y check/ money order/ or credit cardI +ant to pa, -, credit card ./isa or 0asterCard onl,1. 2lease e'ail pa,'ent instructions to the 3ollo+ing emai address:
E-mail address

I ha4e enclosed a chec# or 'one, order pa,a-le to Duke University.

Duke Summer Academy Partici(ant Agreement *A((endi2 A,3 2lease read and sign the Summer Academy Partici(ant Agreement. This agree'ent on page & 'ust -e signed -, -oth the participant and the parent5guardian. Check ist *A((endi2 4,3 Be3ore su-'itting the application( please re4ie+ the Check ist on page 1% to ensure ,ou ha4e attached all supporting docu'entation +ith appropriate signatures. 6e +ill not re4ie+ the application until it is co'plete and pa,'ent has -een recei4ed. A(( icant Information3

irst !ame

"iddle !ame

#ast !ame

$referred irst !ame

Street

%ity

State&$ro'ince

%ountry

$ostal %ode

Telephone

E-mail Address


%onfirm E-mail Address

0ale

7e'ale

(ate of )irth *"-(-+,3 ---- %iti-enship: Ethnicity *optional,:

I choose to speci3, 3ro' the 3ollo+ing ethnic groups: .ispanic or #atino Asian )lac/&African American 0hite 2ther !ati'e American&Alas/an

!ati'e .awaiian&$acific 1slander

I choose not to speci3,

%urrent 3rade in School:

9th

1%th

11th

12th

%urrent %ontact 1nformation *Student,:

Street Address

%ity

State&$ro'ince

%ountry

$ostal %ode

Telephone

E-mail Address

.a'e any members of your family attended (u/e 4ni'ersity5

"o

8es

1f yes, please pro'ide the name*s,, year of graduation, relationship, and email address below, if /nown:
11
!ame

+ear of 3raduation

Relationship

E-mail Address

21

!ame

+ear of 3raduation

Relationship

E-mail Address

91

!ame

+ear of 3raduation

Relationship

E-mail Address

:1

!ame

+ear of 3raduation

Relationship

E-mail Address

%urrent %ontact 1nformation *$arent&3uardian,:

!ame 6 $arent 3uardian 78

 Street Address

%ity

State&$ro'ince

%ountry

$ostal %ode

Telephone

E-mail Address

!ame 6 $arent 3uardian 79

Street Address

%ity

State&$ro'ince

%ountry

$ostal %ode

Telephone

E-mail Address

Emergency %ontact *4.S. based,:

!ame

Relationship

Street Address

%ity

State&$ro'ince

%ountry

$ostal %ode

Telephone

ax

%ell $hone

E-mail Address

%onfirm E-mail Address

School 1nformation:

!ame of %urrent School

Street Address

%ity

State&$ro'ince

%ountry

$ostal %ode

Telephone

ax


School E-mail Address

%onfirm School E-mail Address

T,pe o3 school:

2u-lic

2ri4ate

Boarding

International

Ho'e School

$lease ran/ your e'ening, not-for-credit, course choices: * ine Arts, %hinese or English #anguage, $repare for %ollege Success,
Course "a'e

1. 2. 9.

All applicants must complete the following sections and sign the (u/e Summer Academy 3eneral Agreement orm *Appendix A,:
I. Ha4e ,ou e4er -een placed on an, t,pe o3 acade'ic or disciplinar, pro-ation; "o. 8es. I3 ,es( please e$plain .here or on a separate sheet o3 paper1: 2lease t,pe here .appro$ <%% +ord li'it1. ttach an additional page i3 needed.

II. Ha4e ,ou e4er -een arrested or cited( regardless o3 the outco'e; "o.

8es. I3 ,es( please use an additional page to pro4ide a co'plete e$planation including speci3ic details o3 the outco'e.s1.

The !u#e Uni4ersit, Co''unit, Standard

!u#e Uni4ersit, is a co''unit, o3 scholars and learners( co''itted to the principles o3 honest,( trust+orthiness( 3airness( and respect 3or others. Students share +ith 3acult, and sta33 the responsi-ilit, 3or pro'oting a cli'ate o3 integrit,. s citi=ens o3 this co''unit,( students are e$pected to adhere to these 3unda'ental 4alues at all ti'es( in -oth their acade'ic and non-acade'ic endea4ors. The P edge Students a33ir' their co''it'ent to uphold the 4alues o3 the !u#e Uni4ersit, co''unit, -, signing a pledge stating: 1. I +ill not lie( cheat( or steal in ', acade'ic endea4ors( nor +ill I accept the actions o3 those +ho do. 2. I +ill conduct ',sel3 responsi-l, and honora-l, in all ', acti4ities as a !u#e student. The #eaffirmation Upon co'pletion o3 each acade'ic assign'ent( students +ill -e e$pected to rea33ir' the a-o4e co''it'ent -, signing this state'ent: I ha4e adhered to the !u#e Co''unit, Standard in co'pleting this assign'ent. Student Signature:>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Students5 O) igation to #e(ort Potentia Cases of Academic Dishonesty Under the !u#e Co''unit, Standard( students a33ir' their co''it'ent not to lie( cheat( or steal in acade'ic endea4ors( nor accept the actions o3 those +ho do. Thus( a student +ho has direct #no+ledge o3 a potential case o3 acade'ic dishonest, is re?uired to: 2ro4ide a signed +ritten state'ent o3 the o-ser4ed -eha4ior to !r. "ic#i Charles in The @33ice o3 Su''er Session +ithin one +ee# o3 the alleged occurrenceA and 2ro4ide the na'e or identit, o3 the person.s1 alleged to ha4e co''itted the 4iolation.s1.

The o-ser4ing student is encouraged 3irst to spea# +ith the person.s1 alleged to ha4e co''itted the 4iolation.s1 3or at least t+o reasons: 11 to correct an, 'isassu'ption a-out alleged act.s1( and 21 to let the accused student.s1 #no+ that the situation is -eing reported so that the accused student.s1 'ight choose to sel3-report as +ell. .Contacting !r. "ic#i Charles in The @33ice o3 Su''er Session to accept responsi-ilit, 3or a 4iolation o3 the !u#e Co''unit, Standard prior to the reporting o3 an alleged o33ense +ill -e considered as a positi4e 3actor in the deter'ination o3 an appropriate sanction.1 Students +ho #no+ingl, do not 3ul3ill this o-ligation are the'sel4es su-Bect to sanctions .

III- 66I affirm that a of the information on and associated +ith this form is true and com( ete and that if any of the information changes )et+een no+ and my enro ment at Duke I +i notify the Office of Summer Session +ithin '7 hours66I commit myse f to u(ho d the Duke Community Standard and the University (o icies that (roceed from it and understand that fai ure to do so may resu t in disci( inary action/ u( to and inc uding dismissa from Duke University>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> 2articipants Signature >>>>>>>>>>>>>>>>>> !ate

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> 2arents Signature

>>>>>>>>>>>>>>>>>> !ate

APPENDIX A

Duke University Summer Academy for High Schoo Students Partici(ant Agreement PL"AS" #"AD THIS A8#""!"NT CA#"9ULL:/ IT IS A L"8AL CONT#ACT AND A99"CTS AN: #I8HTS :OU O# :OU# CHILD ; .A#D !A: HA<" I9 H";SH" IS IN=U#"D O# OTH"#.IS" SU99"#S DA!A8"S .HIL" PA#TICIPATIN8 IN TH" DU>" UNI<"#SIT: SU!!"# ACAD"!: 9O# HI8H SCHOOL STUD"NTS P#O8#A!Be a+are that -, registering ,our child5+ard .2articipant1 and ha4ing hi'5her participate in the Su''er cade', 3or High School Students progra'( ,ou(*Parent;8uardian Name Here, >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> and the 2articipant *Partici(ant Name Here, >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> +ill -e +ai4ing all clai's 3or inBuries the 2articipant 'ight sustain arising out o3 his5her participation in the progra'. Assum(tion of #isks3 I56e ha4e read the Su''er cade', 3or High School Students Cuide a4aila-le online and all o3 the in3or'ation associated +ith this application. I56e understand that participation in the Su''er cade', 3or High School Students progra' is 4oluntar, and I56e are a+are that there are situations in +hich students +ill not -e under the direct super4ision o3 Su''er cade', or !u#e Uni4ersit, sta33 'e'-ers. I56e understand that the progra' in4ol4es e$cursions and o33-ca'pus acti4ities and I56e ha4e elected to participate in this progra'. s re3lected -, our signatures -elo+( I56e are a+are o3( ha4e discussed( and accept the ris#s associated +ith and inherent in the Su''er cade', 3or High School Students progra'. 4ehaviora and Academic "2(ectations ; Dismissa from the Program3 6e understand that the progra' is acade'icall, rigorous and designed 3or sel3-'oti4ated and responsi-le indi4iduals. I56e understand that students are e$pected to 'anage their ti'e to co'plete assign'ents -oth in and out o3 the classroo'. I56e understand that

there are ti'es during the progra' that students +ill not -e directl, super4ised -, !u#e sta33. I56e understand the degree o3 super4ision that +ill -e pro4ided and the students responsi-ilit, to 'a#e +ise decisions concerning his5her health and sa3et, +hile enrolled in the progra'. 6e understand that the !u#e @33ice o3 Su''er Session has the right to +ithdra+ and dis'iss an, student +hose -eha4ior is inconsistent +ith the goals and standards o3 the progra'. Should a participant -e dis'issed 3ro' the progra'( the parent5guardian is responsi-le 3or all e$penses( including -ut not li'ited to( air3are( hotels( and 'eals. "o re3unds +ill -e issued. Students dis'issed 3ro' the progra' 'ust depart !u#e Uni4ersit,s ca'pus +ithin 2: hours o3 dis'issal. Lost;Sto en Items3 I56e understand that !u#e Uni4ersit, and !u#e Su''er cade', 3or High School Students are not responsi-le 3or ite's that are lost or stolen and that the student is responsi-le 3or his5her o+n possessions. I56e agree to accept responsi-ilit, 3or e$penses incurred during the progra' 3or lost or da'aged #e,s and cards and da'ages to Uni4ersit, propert, caused -, the student. !a'ages to residence hall roo's +ill -e di4ided e?uall, a'ong roo''ates( i3 one roo''ate does not clai' responsi-ilit, 3or da'ages. !u#e Su''er Session reco''ends that students not -e in possession o3 4alua-le e?uip'ent or 'erchandise during the progra'. Should a student +ish to -ring 4alua-le e?uip'ent or 'erchandise( !u#e Su''er Session reco''ends that this propert, -e insured against loss( the3t( or da'ages. Program "va uation3 I56e agree that the student +ill co'plete ?uestionnaires and other re?uests 3or in3or'ation as part o3 the progra's e4aluation. 6e also agree that photographs or 4ideo o3 the student ta#en during the progra'( +ritings( and other student +or# produced during the progra' 'a, -e used -, !u#e Su''er Session and !u#e Uni4ersit, in reports( pu-lic in3or'ation( and pro'otional 'aterials. !edica ;Insurance #e?uirements3 I56e agree to suppl, all necessar, 'edical in3or'ation as re?uested -, !u#e Su''er Session. I56e agree to pro4ide co'prehensi4e health and accident insurance throughout the duration o3 the progra'. I56e agree to pro4ide e4idence o3 this health insurance to !u#e Su''er Session. I56e understand that this insurance polic, 'ust -e +ritten -, a co'pan, +ith a U.S. address. I56e agree to co4er an, and all 3inancial 'edical o-ligations and agree that !u#e Su''er Session and !u#e Uni4ersit, +ill not -e 3inanciall, responsi-le 3or an, illnesses or inBuries sustained during the Su''er cade', 3or High School Students progra'. Cance ations and #efunds3 I56e ha4e read and understand the 3ollo+ing cancellation and re3und polic, - ll cancellation re?uests 'ust -e 'ade in +riting. I3 the participant cancels 3or an, reason 9% or 'ore da,s prior to the 3irst da, o3 the progra'( !u#e Su''er cade', 3or High School Students and !u#e Su''er Session +ill re3und all paid tuition less the D9%% non-re3unda-le deposit. I3 a 'edical condition necessitates the participants +ithdra+al 3ro' the progra' +ithin 9% da,s prior to the -eginning o3 the session( the progra' +ill re3und the paid -alance 'inus the D9%% deposit 3eeA the 'edical condition 'ust -e docu'ented -, a ph,sician as one that pre4ents participation in the progra'. I3 a 'edical condition necessitates the participants +ithdra+al 3ro' the progra' +hile in session( the progra' +ill re3und housing and dining costs on a prorated -asis 'inus the D9%% deposit. There +ill -e no re3und o3 tuition( student health 3ee( or transcript 3ee. Should a participant -e dis'issed 3ro' the progra'( the parent5guardian is responsi-le 3or all e$penses( including -ut not li'ited to air3are( hotels( and 'eals. "o re3unds +ill -e issued. !u#e Su''er cade', 3or High School Students and !u#e Su''er Session reser4es the right to cancel an, class i3 the 'ini'u' enroll'ent is not 'et or 3or an, reason -e,ond the control o3 !u#e Su''er Session. #e ease and .aiver of Lia)i ity3 In return 3or !u#e Uni4ersit, per'itting the 2articipant to register and participate in Su''er cade', 3or High School Students and ha4ing read and understand the 2articipation gree'ent( I56e 4oluntaril, agree to the 3ollo+ing: . I56e ac#no+ledge( agree( pro'ise and co4enant +ith !u#e Uni4ersit, and its trustees( o33icers( e'plo,ees( agents( and all other persons or entities in4ol4ed in the 2rogra' .Eeleasees1( and do here-, release( hold har'less( and discharge Eeleasees 3ro' an, and all lia-ilit, 3or an, inBur,( death( illness( disease( and da'age to 2articipant or his5her propert, +hich 2articipant 'ight sustain +hile participating in the Su''er cade', 3or High School Students progra' at !u#e Uni4ersit,( and I56e e$ecute this release on -ehal3 o3 and +ith the speci3ic intent to legall, -ind us( our heirs( assigns( personal representati4e.s1( and estate. B. I56e 3urther ac#no+ledge and understand that pictures or 4ideos ta#en o3 participants( or products created and produced -, participants( 'a, -e used in !u#e products( pu-lications( +e- sites and5or

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social 'edia channels .e.g. 7ace-oo#( 8ouTu-e1( or -, organi=ations appro4ed !u#e Su''er Session and !u#e Uni4ersit,. C. In signing this Eelease and 6ai4er( I56e ac#no+ledge and represent that I56e ha4e in3or'ed oursel4es 3ull, o3 the contents o3 this Eelease and 6ai4er o3 Fia-ilit, and hold har'less agree'ent -, reading it -e3ore +e sign it( and that I56e ha4e re4ie+ed it and understand +hat it 'eans and that I56e sign this docu'ent 3reel,. I56e 3urther state that there are no health-related reasons or pro-le's +hich preclude or restrict the 2articipants participation in the Su''er cade', 3or High School Students progra' at !u#e Uni4ersit,.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>> 2articipants Signature !ate

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>> 2arents Signature !ate

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Im(ortant Disa)i ity@#e ated Information !u#e Uni4ersit,( under the pro4isions o3 the 'ericans +ith !isa-ilities ct . ! 1( is prepared to e$plore possi-le co4erage and reasona-le acade'ic adBust'ents and acco''odations 3or indi4iduals participating in !u#e acade'ic progra's. 7or this purpose( a student 'ust ha4e a ph,sical or 'ental i'pair'ent that su-stantiall, li'its one or 'ore 'aBor li3e acti4ities such as( -ut not li'ited to( hearing( seeing( spea#ing( -reathing( per3or'ing 'anual tas#s( +al#ing( caring 3or onesel3( and learning. Su-stantiall, li'iting re3ers to an i'pair'ent that pre4ents an indi4idual 3ro' per3or'ing a 'aBor li3e acti4it, or signi3icantl, restricts the condition( 'anner( or duration under +hich an indi4idual can per3or' a 'aBor li3e acti4it,( as co'pared to the a4erage person in the general population. I'pair'ent does not signi3icantl, restrict a 'aBor li3e acti4it, i3 it results in onl, 'ild li'itations or restrictions. Students ad'itted to Su''er cade', 3or High School Students +ill recei4e in3or'ation a-out the procedure 3or re?uesting acco''odations. Such re?uests should -e 'ade as soon as possi-le to initiate the Uni4ersit,s process to e$plore possi-le co4erage and reasona-le acco''odations under ! . Students are re'inded that recei4ing ser4ices and5or acco''odations in ele'entar, or secondar, schools does not necessaril, ?uali3, a student 3or the sa'e ser4ices and5or acco''odations at a post-secondar, institution such as !u#e Uni4ersit,.

Non@discrimination (o icy !u#e Uni4ersit, prohi-its discri'ination and harass'ent( and pro4ides e?ual e'plo,'ent opportunit, +ithout regard to race( color( religion( national origin( disa-ilit,( 4eteran status( se$ual orientation( gender identit,( se$( or age. The uni4ersit, also 'a#es good 3aith e33orts to recruit( e'plo,( and pro'ote ?uali3ied 'inorities( +o'en( indi4iduals +ith disa-ilities( and 4eterans. It ad'its ?uali3ied students to all the rights( pri4ileges( progra's( and acti4ities generall, accorded or 'ade a4aila-le to students. The uni4ersit, also does not tolerate harass'ent o3 an, #ind.

Duke University Cam(us Safety Under the 3ederal Ca'pus Securit, ct .2% U.S.C. 1%9231( prospecti4e students 'a, o-tain a cop, o3 the Uni4ersit,s annual securit, report -, 4isiting the !u#e Uni4ersit, 2olice !epart'ent at <%2 @regon Street( !urha'( "C or -, calling .9191 G):-:G%2. This report includes ca'pus cri'e statistics and the Uni4ersit,s sa3et, and securit, policies

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APP"NDIA 4

The Check ist

The chec#list -elo+ +ill help ,ou -e con3ident that ,ou are su-'itting a co'plete application +ith all supporting docu'entation. co'pleted application 3or' +ith all necessar, signatures. n essa, stating +h, ,ou are uni?uel, ?uali3ied 3or this progra' as +ell as ,our interest in the da,ti'e classes 3or +hich ,ou are appl,ing. T+o strong paragraphs are su33icient. resu'e highlighting ,our acade'ic and non-acade'ic e$periences. 2lease include an, co''unit, ser4ice or e$tracurricular acti4ities ,ou ha4e participated in( leadership roles ,ou ha4e held( and a+ards ,ou ha4e +on. High School transcript that re3lects all grades and a current C2 .an uno33icial transcript is accepta-le1. Ho'e schooled students are re?uired to su-'it proper docu'entation.

Teacher Eeco''endation 7or'.

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