Summer Mini-College Application

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Name of Child(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Age(Required)

Birthday(Required)

Sex(Required)

School(Required)

Grade (Fall 2026)(Required)

Parents or Guardians(Required)

Address (if different from above)

Street Address Address Line 2 City State ZIP Code

Place of Employment (Mother)

Place of Employment Phone (Mother)

Place of Employment (Father)

Place of Employment Phone (Father)

Emergency Contact Name(Required)

If parents cannot be reached

Emergency Contact Phone(Required)

Emergency Contact Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Contact Relation to Child(Required)

If your child has any type of medical problem, please give details

Child's Physican(Required)

Child's Physican Phone(Required)

Child's Interests and Hobbies

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