High School & Beyond (South Bend, IN) – Application

Personal Information

Name*

First Last

Mother's Name*

Father's Name*

Address*

Street Address City State ZIP Code

Home Phone Number*

e.g. 123-456-7890

Cell Phone Number

e.g. 123-456-7890

Phone Number of Parent (emergency use only)*

e.g. 123-456-7890

Email Address of Applicant

Email Address of Parent*

Date of Birth*

Education

School Currently Attending*

Grade Point Average*

Extracurricular Activities*

High School (if known at time of application)

Miscellaneous

Medical Insurance Company*

Medical Insurance Group Number*

Medical Insurance Policy Number*

Medical Insurance Phone Number*

Electronic Signature for Medical & Photo Release*

As the parent or legal guardian of the participant identified on this registration, I hereby delegate authority to the Directors of "High School & Beyond" to arrange whatever medical treatment they deem necessary for him during the activity. Also, I hereby authorize and consent to the use and reproduction by YSI staff or an authorized agent or assignee of any and all photographs taken of the above-named applicant for the purpose of promoting YSI programs, without any compensation to me. All film, together with any prints, shall constitute property of YSI, solely and completely.

Reference*

Who recommended this program to you?

Comments

Please include any dietary restrictions or medical conditions.

Essay*

Write an essay (e.g., 200 words) on the following topic: “Who is your hero? How can this person’s life influence your high school career?” Applications submitted without an essay will not be considered. (We suggest the essay begin with a brief statement about your hero and why you admire this person. You might follow this with an anecdote that illustrates your hero's admirable traits, and then conclude by explaining how this person's life might influence your high school career.)

You may want to draft your essay prior to completing the online application and then copy and paste it into the box provided.