KHSI 2023: Family Information Form for Rising Seniors
KHSI 2023: College Readiness is a free one-week residential program for 24 rising high school seniors from June 5 through June 9, 2023. The institute is intended for rising high school seniors who wish to learn more about what it means to be part of the Kugelman Honors Program and a Living Learning Community (LLC). Selected students will live together at the center of the Kugelman Honors Program's LLC in Pace Hall on the University of West Florida's campus. Students will engage in discussions and high-impact experiences with UWF Kugelman Honors faculty, staff and students, and community experts.

Please complete the following information by 5:00 p.m. on Friday, May 19  :
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First Parent or Guardian
Title:
First Parent or Guardian
First Name:
 *
First Parent or Guardian
Last Name:
 *
First Parent or Guardian  
Phone Number:
*
First Parent or Guardian  
Email Address:
*
First Parent or Guardian  
Mailing Address (Street Address, City, State, Zip Code):
*
Second Parent or Guardian
Title:
Second Parent or Guardian
First Name:
 *
Second Parent or Guardian
Last Name:
 *
Second Parent or Guardian  
Phone Number:
*
Second Parent or Guardian  
Email Address:
*
Emergency Contact  
Full Name:
*
Emergency Contact  
Relationship to Student:
*
Emergency Contact  
Phone Number:
*
Authorized People to Check-Out Student 
Full Name (required) & Notes (optional):
*
Cost of KHSI 
The Kugelman Honors Program provides the following to KHSI participants:
-Room and board
-Most meals and snacks
-Supplies for workshops and projects

Students will be responsible for purchasing the following: 
- Meals and snacks for two off-campus excursions 
-Souvenirs, if desired
-Any other miscellaneous items *
Student's First Name: *
Student's Middle Name:
Student's Last Name: *
Student's Preferred Name:
Student's Date of Birth: *
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Student Phone Number: *
Student's Email Address: *
Name of School Student Attends: *
Allergies or Sensitivities
Please list below any allergies that your child has. Please include food sensitivities. 
Please describe the degree of the allergy. Can your child touch it, be in the same room, is it only when ingested, etc. We will adjust activities or supplies as necessary for known allergies or sensitivities. We recommend bringing snacks appropriate for any food sensitivities. 
 *
Medical Information
Does your child have any medical conditions that may impact their experience at KHSI or may be helpful to know in an emergency?
 *
Diagnosed Disabilities or Disorders
Please select any of the following neurological, behavioral, or physical disabilities or disorders that your child has had diagnosed. *
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