Website: ces.uvi.edu    Phone: (340) 693-1080   Email: ces.uvi.edu@gmail.com 
Agriculture Enrichment Summer Camp at UVI Cooperative Extension Service 
Participant Application 2016 
Camp Dates: June 27 to July 22, 2016  
 
Name: __________________________ Gender: ___ Social Security #:_____________________ 
Date of Birth: ___________________ Age: ____ Today’s Date: __________________________ 
Home Address: __________________________ Mailing Address: ________________________ 
City: ________________ Zip: ________ City: __________________ Zip: _________________ 
Telephone No.: (Home) _______________________ (Cell) _____________________________ 
Email: ________________________________________________________________________ 
Person to notify in case of emergency: 
Name: _________________________ Relationship: ______________ Phone #: _____________ 
Ethnicity: 
 Black - not Hispanic  
 Hispanic  
 Asian 
 White - not Hispanic 
 American Indian 
 Decline to Answer 
 
Education Status: 
Highest Grade Completed  _____ 
Other Summer or Training Programs Completed:______________________________________ 
 
Disability/Disabilities: (Please leave blank if you have no disability) 
Primary: __________________________ Secondary: __________________________________ 
Strengths: _____________________________________________________________________ 
Weaknesses: ___________________________________________________________________ 
Means of Transportation: Bus/Safari: ___ Vitran Plus: ___ Drive Self: ____ Driven: ________ 
 
By signing below, I certify that the information provided is true to the best of my knowledge. I 
am also aware that the information I have provided is subject to review and verification and that 
I may have to provide documents to support this application. 
Participant’s Signature: _______________________________________  Date: _____________ 
Parent’s/Guardian’s Signature: _________________________________ Date: ______________ 
SIGN
SIGN