UVa-Wise Governor's School Student Application

Summer 2013 Program runs June 23th through July 13th

(Participating students must be in attendance through the duration of the program.)

We are looking for driven and responsible students who have demonstrated mature and significant achievement in theater—onstage or behind the scenes. Generally, these students should also excel academically, particularly in communication, English and the humanities. This program is focused on bringing Shakespeare’s texts into performance. It is intense and demanding, both intellectually AND physically! Students will be involved in strenuous activity for significant portions of the day for three weeks straight. So, lots of energy and a positive attitude are fundamental to a successful candidate for the program. Students who come without such willingness hinder the morale and progress of the entire program and preclude other students from participating. As this is a residential program for which students receive college credit, participants are required to remain on campus throughout the entire 3 weeks of the program. Please consider these factors in your nominations.

In an effort to simplify the admissions process, this application form may completed by a teacher, administrator, the student applicant or the applicant’s parent. An Official of the school district (usually the gifted coordinator) will rank multiple applicants from their district once the submission deadline has passed, if needed.

Please use this form to nominate each student for participation in the UVa-Wise Governor's School in Theater Arts. Fields with asterisks are required. Please contact theater@uvawise.edu with any questions.

Student Applicant's First Name: *

Student Applicant's Last Name: *

Applicant's Sex: *

Applicant's Age: *

Applicant's Birthdate: *

Applicant's Current Class Year: *

10th Grade (Sophomore)

11th Grade (Junior)

The UVa-Wise Governor's School program is only available to current Sophomores and Juniors.

Applicant's Grade Point Average (if available):

Applicant's Phone Number: *

Phone Number at which the student applicant can be reached.

Applicant's Email Address (if available):

Please double-check entry. A copy of this form will be emailed to this address once submitted.

Address/es

Residential/Mailing Addresses:

Please list the student Nominee's residential address (for use only in the event of an emergency). If the nominee's mailing address is different from his or her residential address, please click on the red mailing address link at the bottom of the residential address input box and enter the nominee's mailing address information where applicable.

Residential Street Address:

number and street name where applicant resides

Apartment/Unit Number (If applicable. Not a P.O. Box)

Click the link above to enter an apartment or unit number at a residential address (not a P.O. Box)

Apartment/Unit Number:

If applicable, please enter the appropriate descriptor/abreviation (apt,unit,suite,etc.) and the corresponding numbers/letters to identify the residence ("suite 123B")

City: *

State: *

To be eligible, Governor's School students must reside in the state of Virginia.

Zip Code: *

Mailing/Residential Address: *

The student's residential address is his/her mailing address.

The student's mailing address is different than his/her residential address. (please click the link below to enter a mailing address)

Enter a Mailing Address (if different than Residence)

Please select the link to enter a P.O. box or the link to enter a street address at which the applicant receives mail.

P.O. Box (if applicable)

P.O. Box (if applicable):

Mailing Street Address (if applicable)

Mailing Street Number and Name:

Mailing Apartment/Unit #

Mailing Apartment/Unit #:

City (mailing address):

State (mailing address):

Eligable students must reside in Virginia.

Mailing Zip Code:

Parent or Legal Guardian's Information

First and Last Name of applicant's Parent or Legal Guardian: *

Parent/Legal Guardian's Home Phone Number: *

Parent or Legal Guardian's Email Address:

Please double-check entry. A copy of this form will be emailed to this address once submitted.

Enter Alternate/Additional Contact Information

Cell Phone Number:

Work Phone Number:

Other Contact number:

Additional Email Address:

Enter a Secondary Contact Person (welcomed but not required)

Secondary Contact's First and Last Name:

Secondary Contact's Home Phone Number:

Secondary Contact's Cell Phone Number:

Secondary Contact's Work Number:

Other Number for Secondary Contact:

Relationship of Secondary Contact to student applicant:

Secondary contact listed here is also a custodial parent or legal guardian of the student applicant.

Secondary contact is a parent with limited or no custody of the student applicant.

Secondary contact is a relative of the student applicant.

Secondary contact is a step-parent of the student applicant.

Secondary contact is a family friend of the student applicant.

Enter any Legal Custodial issues involving the Student Applicant (if applicable-Not required.)

Notes on Legal Custodial issue with a student applicant's parent:

School District Information

Name of Applicant's School District: *

Name of Applicant's High School: *

Phone Number of the Applicant's High School: *

Name of the Applicant's Guidance Counselor:

Teacher's/Director's Evaluation Information

Please provide contact information for a theater, speech, or similar teacher/coach, who can submit an evaluation of the student's work in that field. If the evaluator does not have an email address, please enter alternative contact information. The evaluation can be completed at www.uvawise.edu/govschool/evaluation .

Name of the Teacher, Director (or similar) who will provide an evaluation of the student applicant: *

Relationship of Evaluator to Student Applicant: *

High School Speech or English Teacher

High School Art or Music Teacher/Director

High School Theater Teacher/Director

Community Theater Director

Other Theater Director

Other Theater/Acting Teacher

Other Art/Music Teacher or Director

Technical/Design Teacher or Director

Other/not listed

Select all that apply

Email of the Evaluator:

We need to direct the evaluator to the website of the evaluation form. If the evaluator does not have or regularly use an email address, please provide an alternative means of contacting the evaluator below.

Alternate Contact for Evaluator (only if no email address is available)

Evaluator's Alternate Contact Information:

First and Last Name of Individual filling out this form: *

Email Address of Individual filling out this form: *

Please double-check entry. A copy of this form will be emailed to this address once submitted.

Daytime Phone Number of Individual filling out this form: *

Authentication: *

By submitting this form, I assert that all the information contained herein is accurate to the best of my knowledge and that I have not intentionally misrepresented anyone's identity, relationship, or personal information.