The Cambridge College Programme LLC

Academic and Leadership Programmes

Scholar Application Form
Part I: Personal Information
Full Name (print or type): __________________________________________________________________
last first middle initial
Please circle your sizes for Programme shirts:
Please check:
Male T-shirt (circle size): S M L XL XXL
Female

Sweatshirt (circle size): S M L XL XXL

Home address (print or type): _________________________________________________________________

(IF A PO BOX, PLEASE ALSO INCLUDE A PHYSICAL ADDRESS FOR FEDEX DELIVERY OF PROGRAMME MATERIALS.)

City:_____________________________________________ State:_________________ Zip:___________

Telephone:_______________________________ Family E-Mail:_________________________________

area code number please print

I have been on the Programme before My sibling _____________________ participated in_______

(name) (year)

Citizenship: United States Other citizenship (please specify): _______________________________

(no visa required) If not a US citizen, check to see if you need a visa for the UK or France.
This is the applicant’s family responsibility only.

Birthdate:_________________ Passport number: _____________________________ Exp. date: _________

month / day / year (May be sent at a later date. Be sure it will not expire before Jan. 15, 2010.)

Current Grade: Senior Junior Sophomore Freshman Rising Freshman

GPA: ____________ SAT or PSAT score: ____________ ACT score: ____________

(Only necessary if you have current scores)

Discuss your academic and extracurricular activities and achievements on a separate page. This information is
needed for roommate/group and dorm assignment, and staff selection.
Medical or emotional conditions that will require special attention, treatment, or medication on the Programme
(Read “Health Care” on page 37 and attach additional pages as necessary.)
_______________________________________________________________________________________
_______________________________________________________________________________________
Does any prescription or OTC medication contain alcohol? Yes No If yes, please list:
_______________________________________________________________________________________
I wish to have a roommate. (Most rooms are singles. The number of double rooms is limited. All bathroom
facilities are dormitory style on same floor.) I wish to live next door to:
If a specific person(s), please name: ________________________________ (Scholars must verify this in writing.)
I wish to have a private bathroom for an additional fee of $500. The number of private bathrooms within each
bedroom is limited. This is a first-come, first-serve basis.
Paris optional trip August 11th - 17th. A $2,300 fee.
 Part II: Emergency Contact Information
For Home Addresses, you may write “Same” if they are the same as the scholar’s. Please give at least two numbers, including
the area code, and indicate after them whether they are Home Telephone (HT), Office Telephone (OT), Cell/Mobile Phone
(C), Home Fax (HF), Office Fax (OF), or Beeper/Pager (B).

Please notify the Programme immediately if any change occurs in the information below.

If you will be moving, travelling, or at a summer home any time after June 1, please provide an address where
we can send the scholar’s final package, and contact numbers.

Father: Mr., Dr., other______________________________________________________________________

last first middle initial

Occupation: ____________________________________________________________________________

Home Address: _________________________________________________________________________

street city state zip code

Contact Numbers: _______________________________________________________________________

E-Mail Address: _________________________________________________________________________

please print

Mother: Mrs., Ms., Dr., other______________________________________________________________

last first middle initial

Occupation: ____________________________________________________________________________

Home Address: _________________________________________________________________________

street city state zip code

Contact Numbers: _______________________________________________________________________

E-Mail Address: _________________________________________________________________________

please print

In the case of an emergency when parents are unavailable, please contact:

Name(s): Mr., Mrs., Ms., Dr., ______ __________________________________________________________

last first middle initial

Mr., Mrs., Ms., Dr., ______ ___________________________________________________________

last first middle initial

Relationship to applicant: ______________________________________________________________

Address: _______________________________________________________________________________
street city state zip code

Contact Numbers:________________________________________________________________________

E-Mail Address:__________________________________________________________________________
 Part III: Academic Information
School name: ___________________________________________________________________________

Counselor: Dr., Mr., Mrs., Ms., Fr., Sr. ___________________________________________________________

School address: _________________________________________________________________________

street city state zip code

School telephone: ________________________________________________________________________

area code number e-mail

Please check only one:

Academic Programme
International Leadership Programme

Part IV: Academic Programme Course Choices

Please indicate your first, second, and third choices, by writing “1,” “2,” “3” beside courses, for Class I:

__Abnormal Psychology __History of Art __Medical Science: Biomedical __Quantum Gravity

__Cognitive Neuroscience __Hitchhiker’s Guide to Ethics __Quantum Physics
__Computer Science Physics __Musical Theatre __Scriptwriting
__Cosmology __International Law __Nanotechnology __Shakespeare
__Criminal and Forensic __International Relations and __Philosophy of Mind __Shakespeare’s Hamlet
Psychology Terrorism __Philosophy: Nature and __Special Relativity
__Developmental Psychology __Introduction to Archaeology Destiny __Studio Art
__Economics __Introduction to Veterinary __Photography __Superstrings
__Existentialism Medicine __Political Theory __War and Chivalry
__Fantasy Literature __Journalism __Psychology and Law __World War II
__English Literary Villains __Law: The Moot Court __Psychology of War
__Egyptology __Marine Biology __Psychology: Journey Inwards

For all Academic and Leadership scholars, Class II is British Cultural History.

Please indicate your first, second, and third choices, by writing “1,” “2,” “3” beside courses, for Class III:

__Abnormal Psychology __DNA Fingerprinting __Jane Austen’s Novels __Political Theory

__Alfred Hitchcock __Drama __Latin __Psychological Disorders
__Architecture and History __Economics: Game Theory __Law: The Moot Court __Psychology and Law
__Biological Neuroscience __Egyptology __Major World Religions __Psychology of War
__British Intelligence __Ethology __Military History __Psychology: Journey Inwards
__Computer Science __Evolutionary Biology __Philosophy: Nature and __Quantum Physics
__Creative Writing __Fantasy Literature Destiny __Superstrings
__Debate __Introduction to Archaeology __Photography __World War II
 Part V: Agreement of Applicant

I understand that an evaluation report from my courses will be given to me for inclusion in my high school or college
file. This will be the original and only copy, and if lost, cannot be replaced.

I agree to conform to all of the conditions and regulations of the colleges and the University of Cambridge, and to
abide by all the rules of the Cambridge College Programme LLC. I understand that: 1) the possession or use of drugs,
alcohol or tobacco; or, 2) the association with individuals not on the Programme violates the rules of the Programme
and the Colleges. I understand that, if I am suspected of violating the zero-tolerance rule regarding alcohol, I will
be subjected to a breath test, and if the results are positive, I will be dismissed from the Programme, my parents/
guardian will be immediately notified, and they must make arrangements at their expense for my return home within
24 hours. I understand that failure to abide by these rules, and by a detailed list of Programme, college and University
rules that I will receive—and which will be reiterated in the Handbook and upon orientation at Cambridge—will
lead to dismissal and my return home at my own expense. Any pranks, such as tampering with the fire extinguisher,
damaging college or University property, will result in an invoice from the college to be sent to your parents and
possible dismissal from the Programme upon college recommendation. I understand that in this case no refunds
will be given. No second chances will be granted. If any of these rules are broken within the final days or hours of
the Programme, I understand that I will be dismissed from all Programme classes, activities and excursions,
including group departure to airports, and will have to notify my parents to make private arrangements for
transportation to the airport, at their expense.

___________________________________ _________________
signature of applicant date

Part VI: Photo

Please attach your photo to this application. Do not send any photo over 2” by 2”—Head shot only, please. Put your
name on the back. The photo will be used for security purposes at the Colleges and will help counsellors to know
your scholar upon arrival. If not available when completing this application, it may be sent later. Pictures must be
received by June 1st.

Attach Photo Here

(name on back)
 Part VII: Optional Offerings (No Fee)
Academic and Leadership Programmes
I wish my son/daughter to be enrolled in one of the following afternoon optional offerings from 3:15 p.m. to 6:00 p.m. All
offerings meet for 10 sessions, 90 minutes or 120 minutes for SAT/ACT/PSAT Prep, unless specified. Scholars do not have
to enroll in any of the below offerings, as this is a free period of time to explore Cambridge with friends, have tea, WiFi
home, study time, or relax on the college campus prior to dinner and supervised evening activities. You may only select
one offering, with the exception of the Cambridge Application Workshop. See pages 24 - 26.

My son/daughter does not wish enrollment in any of the optional offerings.

Theatre production of Shakespeare’s Comedy of Errors, or A Midsummer Night’s Dream
Choir
Battle of the Bands Competition (electric guitar and drums provided)
Review course for the PSAT, SAT and ACT exams. Five sessions only for the first five days.
Calculus.
Cambridge Application Workshop. Three sessions only during the second week. You may select any of the other
optional offerings in addition to this offering, as there will not be a conflict of time.
The Beatles and the Birth of Student Power lectures and an excursion to Apple Studio and Abbey Road. Scholars enrolled
in Marine Biology, Drama, Musical Theatre, Hamlet, and Shakespeare will be at the London Aquarium and Globe
Theatre Workshop, respectively, during the Abbey Road excursion. If you wish to be enrolled in this lecture series, and
you are taking courses visiting the Aquarium or Globe Workshop, you cannot do the Abbey Road excursion.
Rowing/Crew. A Certificate of Attendance is provided.
PGA Golf instruction. Limited enrollment. Equipment provided. A Certificate of PGA Golf Attendance is provided.
Community Service Activities in Cambridge. A total of 10 hours. Certificate of Community Service Hours provided
upon completion for your high school. Be sure to check with your high school, if community service in the UK is
acceptable for service hours.

___________________________________ _________________
signature (relationship) date

Part VIII: Payment Information

Person(s) responsible for payment of tuition:
Bill to: Both Dad Mom Other

Name(s): ______________________________________________________________________________
last first middle initial

Address: _______________________________________________________________________________
street city state zip code

Name(s): ______________________________________________________________________________
last first middle initial

Address: _______________________________________________________________________________
street city state zip code
 Part IX: Approval by Parent or Guardian
I have read the Cambridge College Programme LLC brochure and give permission for my son/daughter to participate
in this Programme. I certify that the enclosed information and medical details are correct. I will read the Programme
Handbook with my son/daughter upon receipt, and will abide by all rules and regulations set forth therein.

If my son/daughter is suspected of violating the zero-tolerance rule regarding alcohol, I agree that the Programme may
conduct a breath test on him or her. If the results are positive, I understand that I will be notified immediately and must
make arrangements at my own expense for my son/daughter to return home within 24 hours.

I agree to accept and pay all expenses if my son/daughter damages college property or is sent home for violating the
rules—with no refund. If rules are broken in the final days and time does not permit being sent home, the scholar will
be formally dismissed from the Programme and may not participate in any classes or group events, including group
departure to airports. I understand that I will be notified of this, and that private transportation to the airport will have
to be arranged at my expense.

I agree to this application and the financial arrangements involved. I understand that it is necessary for my son/daughter to
comply with all conditions and regulations of the Cambridge College Programme LLC, the colleges, and the University of
Cambridge, and I accept the consequences of failure to comply. Any pranks, such as tampering with fire extinguishers,
damaging college or University property, will result in an invoice from the college to be sent to your parents and
possible dismissal from the Programme upon college recommendation. I understand that although the Cambridge
College Programme LLC and its organizers will take reasonable care in the selection of facilities and services, such as
transportation companies and agencies, and will exercise reasonable care for Programme members and their personal
property, there are many risks inherent in any travel program of this nature. I agree to and hereby release the Cambridge
College Programme LLC and its faculty, organizers, and agents from all liability and responsibility of any kind for any loss
or damage to property or personal injury incurred by my son/daughter whilst participating in this Programme.

I grant the Cambridge College Programme LLC faculty and organizers the full authority to take whatever actions they
may deem necessary under the circumstances regarding my son/daughter’s health and safety, and I release each of them
from any liability for any such decisions that they may make. If it is decided to transport my son/daughter back to the
United States by commercial airline or otherwise, I authorize them to make such a decision at my expense.

I agree to pay the balance of the tuition within 30 days of receipt of our invoice. I understand that my scholar is not
fully enrolled until receipt of full payment and the travel form. I also understand that full tuition is non-refundable for
withdrawals for any reason after May 1st.

I agree that statements and photos of my son/daughter may be used in future publicity of the Programme.

___________________________________ _________________
signature (relationship) date

Please return this application form with a check for $195 made payable to the Cambridge College
Programme LLC, to: Ms. Taryn Edwards, Director, Cambridge College Programme, The John Hancock
Building, 175 East Delaware Place, Suite 5518, Chicago, IL 60611. To ensure delivery, please send by
registered mail, FedEx, DHL, so that you may track receipt of delivery.