C L E V E L A N D

INSPIREyour Curiosity!

2017-2018 Student Application

STUDENT APPLICATION

Student Name

Email

Address City State Zip

Telephone Date of Birth Age Sex

Parent/Guardian

Email Telephone

Address City State Zip

Employer Employer’s Telephone

Emergency Contacts

Name Relationship

Address Phone

Name Relationship

Address Phone

School you will be attending in August 2017?

Grade you will be in August 2017?

What is your shirt size? (Please Circle)

S M L XL 2XL 3XL

Have you participated in STEP previously? YES NO

On a scale of 1–10, How would you rate your previous experience? 1=poor 10=excellent 1 2 3 4 5 6 7 8 9 10

Student Signature

Date

Parent/Guardian Signature

Date

gives students the opportunity to visit premier institutions, interact with professionals in the field, meet new friends and work together performing exciting experiments that make science, technology, engineering and math come alive.

Please complete this application by Monday, July 10th and send to EducationAndOutreach@ClevelandWater.com. For more information, please visit www.ClevelandWater.com/ClevelandSTEP or call our Education and Outreach Office at 216-664-3173.

Students entering the 6th through 9th grades at any school in the Cleveland Water/NEORSD service area

Free, fun, safe and age-appropriate activities vetted by STEM professionals through Cleveland STEP

9 a.m. to 1 p.m. one Saturday of each month September through April

WHO:

WHAT:

WHEN:

C L E V E L A N D

Revised June 2017 STEP APPLICATION | 2

EMERGENCY MEDICAL AUTHORIZATIONStudent Name

Address City State Zip

Telephone Date of Birth Age Sex

PARENT/GUARDIAN CONSENT

Purpose - To enable parents to authorize emergency treatment for children who become ill or injured while under Cleveland STEP authority, when a parent or guardian cannot be reached. Please grant consent by filling out Part 1: To Grant Consent below. If you do not authorize emergency treatment complete Part 2: Refusal To Consent information below.

PART 1: TO GRANT CONSENTIn the event reasonable attempts to contact __________________________________ at ________________________(phone number) or ______________________________________(other Parent/Guardian) at _____________________________(phone number)

have been unsuccessful, I hereby give my consent for; (1) the administration of any treatment deemed necessary by

Dr. _______________________________(preferred Physician) or Dr. __________________________ (preferred Dentist),

or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the student to

____________________________ (preferred hospital) or any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained BEFORE the surgery IS PERFORMED. Please provide facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:

Parent/Guardian Signature

Date

PART 2: REFUSAL TO CONSENTI do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the Cleveland STEP authorities to take no action or to:

Parent/Guardian Signature

Date

STEP APPLICATION | 3Revised June 2017

STUDENT ESSAY

NEW STUDENTS, please write several paragraphs explaining why you would like to be a student in the 2017-2018 Cleveland STEP (Student Technical Enrichment Program) including what you hope to get out of your participation in this program.

RETURNING STUDENTS, please explain why you would like to continue your participation in Cleveland STEP.NOTE: You can attach a typed copy instead.

STEP APPLICATION | 4Revised June 2017

ACTIVITY PERMISSION SLIPPERMISSION REQUESTED

Permission is requested for any trips during the Cleveland STEP, September 2017 to April 2018, for which the student would leave the City of Cleveland’s Carl B. Stokes Public Utilities Building/Cleveland Water under the care of the Cleveland STEP Coordinator or other authorized Cleveland STEP Committee or Sub-Committee Members. The dates and locations of trips are as listed on the program schedule given out at the orientation meeting. In case of a change in the program schedule, parents/guardians will be notified prior to that activity.

Tentative Program Schedule

August 26, 2017 By this date, we will confirm your admittance to the program and email you orientation materials, tour schedule, and other documents.

September 16, 2017

Students and parents join us for our first session where we will conduct a short orientation.

Following the orientation students and parents will participate in NEORSD (North East Ohio Regional Sewer District) Open House activities including a tour of the Southerly Waste Water Treatment Plant facilities.

October 21, 2017

Tours depart and return from:Carl B. Stokes Public Utilities BuildingCleveland Water1201 Lakeside Avenue, Cleveland, OH 44114

November 18, 2017

December 9, 2017

January 20, 2018

February 17, 2018

March 17, 2018

April 28, 2018 Final Session1201 Lakeside Avenue, Cleveland, OH 44114

SIGNATURE

_____________________________________ (Student Name) has my permission to participate in Cleveland STEP related activities indicated above.

Parent/Guardian Signature

Date

STEP APPLICATION | 5Revised June 2017