ACT-SO REGISTRATION FORM *

Academic, Cultural, Technological, and Scientific Olympics

Bloomington-Normal NAACP ACT-SO
P.O. Box 385
Bloomington, IL 61702

Date Date / MM / DD YYYY
Student Profile
Student Name Student Name First Middle Last
Age
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female Other
High School
Grade
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email
Graduating Seniors: Are you planning to attend college?

Graduating Seniors: Are you planning to attend college? Yes No
Parent/Guardian Name Parent/Guardian Name First Last
Parent/Guardian's Cell Parent/Guardian's Cell - ### - ### ####
Parent/Guardian Email
How did you hear about ACT-SO?
Newspaper Radio Web site Student Ambassador Teacher Former Participant ACT-SO Volunteer Social Media Other Other
Are you a McLean County Resident?

Are you a McLean County Resident? Yes No
Please select the categories of interest to you.

(Three (3) categories maximum)
HUMANITIES

HUMANITIES Music Composition Short Story Playwriting Poetry-Written Original Essay
BUSINESS

BUSINESS Entrepreneurship
PERFORMING ARTS

PERFORMING ARTS Dance: Ballet Dance: Contemporary Dance: Modern Dance: Traditional Dramatics Oratory Music Instrumental (Classical & Contemporary) Music Vocal (Contemporary & Classical) Poetry - Performance
STEM

STEM Architecture Biology/Microbiology Chemistry/Biochemistry Computer Science Earth and Space Sciences Mathmatics Engineering Medical and Health Physics
VISUAL ARTS

VISUAL ARTS Drawing Painting Photography Sculpture Filmmaking/Video
Media Release

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the Student named above. I also grant to the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the Bloomington-Normal ACT-SO and its volunteers from all claims, demands, and liabilities whatsoever in connection with the above.
I give parental consent. I DO NOT give parental consent.
Parent and Student Accountability

The mission of the Bloomington-‐Normal ACT-‐SO program is to nurture excellence and provide positive reinforcement to African-‐American high school students. We will accomplish this by engaging students in a quality 7-‐month program of monthly enrichment sessions, educational/informational sessions, a community volunteer project, mentoring opportunities, field trips, and more. Students are expected to be fully engaged and committed; and their parents/guardians are expected to support, monitor, and encourage their participation.

Through the commitment of our supporters, partners, volunteers, and steering committee, we will provide leadership, encouragement, and guidance. The responsibilities of parents and students are as follows:
Please check boxes

Please check boxes Attend the Enrichment and Coaching Sessions. Volunteer to serve on a committee. Complete student registration.
Comments:
Student Name Student Name First Middle Last
Student Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Parent/Guardian Name Parent/Guardian Name First Middle Last
Parent/Guardian of Participant Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
* Registration includes a year member in the NAACP.

ACT-SO REGISTRATION FORM *

ACT-SO REGISTRATION FORM *

Student Profile

How did you hear about ACT-SO?

Please select the categories of interest to you.

Media Release

Parent and Student Accountability