Project SUCCEED: Computational Chemistry Workshop

Application Form for Explorations in Computational Science: Chemistry

Directions: use this form to apply for the Computational Chemistry program, Summer 1997. Once you have submitted this form, we will contact you with more information You can submit this form online by filling in the appropriate information and clicking on the "Submit" button at the bottom of the page, or you can print this form, fill in the information, and fax to (919) 286-7876.

Student's Name:

Name of Parent or Legal Guardian:

Address:

City:

State

Zip Code

Daytime Telephone Number

Evening Telephone Number

E-mail (if any)

School Name:

Teacher Name (or other academic reference):

School Phone Number:

Preferred Session (if more than one session is possible, please rank according to your preference with #1 as your first preference):

Grade of student
(if you are a home school student, estimate an approximate grade level):

Age of student (as of March 15, 1997):

Briefly describe your experiences in chemistry (classes, self-study, extracurricular programs, summer activities, etc.):

How did you hear about the program?:

I would like to request a full or partial scholarship due to financial need.

Briefly describe why you wish to participate in this program and what you hope to accomplish:

Additional comments or questions:

Once you have submitted your application, a staff member will contact you either by phone or by email to confirm acceptance into the program.