UNMC Community Academy Application

Participation Summer Session 1
Summer Session 2
Summer Session 3
Fall/Winter
Participation Status New
Current
Past
Name
Mailing Address
City, State, Zip
Telephone
Gender Male
Female
Date of Birth mm/dd/yyyy
Email Address
Expected High School Graduation Year
School now attending
Mother/Legal Guardian's Name
Place of Employment
Work Number
Father/Legal Guardian's Name
Place of Employment
Work Number
Race/Ethnicity African-American
Asian/Pacific Islander
Eastern Indian
Euro-American (Caucasian)
Hispanic/Latino-American
Native-American /Alaskan-Native
Other
Special Accommodations
How did you learn about the UNMC Community Academy?
Adult T-Shirt Size Small
Medium
Large
X-Large
XX-Large
Note: include your name as part of the filename. Do not use periods in your filename.
Applicant Essay (Word Document)

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into the space below.
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