2011 Close up Application

2016 CLOSE UP APPLICATION

THIS FORM MUST BE COMPLETED AND SIGNED BY YOUR PARENT OR GUARDIAN BEFORE YOU CAN PARTICIPATE IN THE CLOSE UP, D.C. PROGRAM OR FUNDRAISERS. PLEASE PRINT ALL INFORMATION LEGIBLY. AFTER APPROVAL OF YOUR APPLICATION YOU WILL RECEIVE A CODE TO ENROLL ONLINE WITH CLOSE UP. YOUR NON-REFUNDABLE DEPOSIT IS DUE AT THE TIME OF ENROLLMENT.

STUDENT NAME______GRADE______HOME ADDRESS______HOME PHONE______STUDENT PLACE OF EMPLOYMENT______

MOTHER’S NAME______PHONE # (IF DIFFERENT)______E-MAIL CONTACT:______EMPLOYMENT______WORK or CELL#______

FATHER’S NAME PHONE # (IF DIFFERENT)______E-MAIL CONTACT:______EMPLOYMENT______WORK or CELL#______

SCHEDULE – PROVIDE NAME OF THE COURSE & TEACHER FOR YOUR FIRST SEMESTER Course Teacher Name HOMEROOM #______1ST Period______2ND Period______3rd Period______4th Period______5th Period______6th Period ______7th Peirod ______

LIST PAST AND PRESENT CLUBS AND ACTIVITIES YOU PARTICIPATE(D) IN AT SATSUMA. BE SURE TO INDICATE WHEN YOU PARTICIPATED. ALSO INCLUDE ANY OFFICES OR AWARDS YOU HAVE RECEIVED. YOU MAY ALSO INCLUDE CHURCH, COMMUNITY, SPORT, AND VOLUNTEER ACTIVITIES.

PLEASE HAVE TWO TEACHERS (PAST OR PRESENT) SIGN BELOW TO RECOMMEND YOU FOR THE CLOSE UP PROGRAM.

1.______2.______LIST ALL DISCIPLINE PROBLEMS YOU HAVE HAD THIS YEAR OR LAST YEAR INCLUDING SUMMER SCHOOL OR OTHER SCHOOLS YOU ATTENDED. BE SPECIFIC. IT WILL BE CHECKED. YOU ARE INELIGIBLE TO PARTICIPATE IF YOU HAVE HAD A SUSPENSION THIS YEAR OR LAST YEAR. OTHER DISCIPLINE PROBLEMS MAY ALSO PROHIBIT YOUR PARTICIPATION.

************************************************************************* ______has my permission to participate in the 2016 Close Up Program in Washington, D. C. He/she may also participate in fundraising events. I understand he/she will be responsible for full payment of fundraising items he/she does not sell or turn in. Donations and fundraising money are not refundable or transferable. PARTICIPATION IN FUNDRAISERS IS OPTIONAL FOR ALL STUDENTS. DONATIONS, FUNDRAISING MONEY, AND PAYMENTS BY EACH STUDENT ARE APPLIED 100% TO THEIR INDIVIDUAL ACCOUNT.

THERE IS A $400.00 NON-REFUNDABLE DEPOSIT FOR CLOSE UP. (IT IS APPLIED 100% TO YOUR CHILD’S PROGRAM COST ). A student cannot share in fundraising activities until they have paid their deposit in full. Total payment for the trip will be September 25, 2016 (6 weeks before trip). Close Up requires this early payment date so they can finalize hotel reservations and airline tickets. Students should start getting donations and fundraising now. I have letters prepared for them to take or send to potential donors as soon as they are enrolled. All donations they obtain from individuals and businesses are applied 100% TO THEIR ACCOUNT. Donations are tax deductible for businesses and individuals.

______PRINT STUDENT NAME GRADE DATE

______PRINT PARENT NAME

______PARENT/GUARDIAN SIGNATURE DATE

Please feel free to contact me at any time if you may have questions. This program will be an experience your child will cherish their entire lives. Kevin Rawls Close Up Sponsor [email protected] – 380-8190

* If I do not respond to your e-mail within 24 hours please try to call or send a message with your child. Our server may be down or sometimes it blocks e-mails.