UAMS.EDU

Application for JSA

Please complete the following application using proper English grammar and avoid all-caps.

  • 1. Student Information

  • Please check all that apply.
    This is for statistical purposes only.
  • This is for statistical purposes only.
  • 2. Student Education

  • Please input the level of schooling the student is currently in (Spring 2017).
  • Please type in the full name of the kindergarten/pre-school, elementary, intermediate, or middle school the student is currently attending (Spring 2017).
  • 3. Parent Information

    Parents and guardians of the student, please enter your information under this section.
  • For the purpose of emergency contact.
  • Important information regarding this program will be sent to you via email.
  • 4. Additional Student Information

  • Please briefly list the activities that the student has or is currently participating. Additionally, please briefly list the academic and extracurricular achievements of the student (explain named awards if necessary).
  • 5. Academy Release Form

    For the parent/guardian to fill out.
  • In the event I cannot be contacted to give my consent, I hereby authorize the CDA and Junior STEM Academy staff and employees to: 1. The administration of any treatment deemed appropriate by a licensed physician or dentist, and 2. The transfer of the minor to any hospital reasonably accessible.
  • The above named student has my permission to participate in Junior STEM Academy sports activities.
  • I give my consent for my child to be administered the following non-prescription medication by the staff when necessary. Other medication that may be required by the student must be supplied by the parents and brought to the camp in the original container properly labeled with the name of the student and identification of the medication, the dosage and the time to be administered.
  • Please list all allergies that the student has. Also list other food, allergy, or substance to which your student may have a reaction. If there is none, please write "None".
  • I give my consent to allow the following person(s) to pick up my child in my absence. Please list their name and cellphone.
  • Appropriate legal documents should be sent to us if a parent in NOT permitted to pick up a child.
  • I hereby permit UAMS/SSDP camp to use, in whole or in part, photographs, videos, and written extractions of the above named camper for the purpose of illustrations and publications, including the UAMS/Center for Diversity Affairs website: cda.uams.edu. No camper’s name will be published.
  • By clicking "Submit", you agree that:

    • 1. Both the student and parent(s) have read the program description and agreed to its content and rules, and
    • 2. The information provided in this application is both complete and accurate.

To complete the rest of the application, please mail a $15 non-refundable application fee in form of a check payable to UAMS Center for Diversity Affairs:

Center for Diversity Affairs
4301 W. Markham St., Slot 625
Little Rock, AR 72205
Memo: JSA/Child’s name