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OVPAA-SWP Form 10.

0 VISSER Summer Workshop Program Application Form Name of UP Incoming Freshman (Last, First, Middle) Constituent University Sex Home Address Dept/College Birthdate Degree Program Admitted Age

Contact details Landline: Mobile: E-mail: Description and/or illustration of an instrument that s/he would like to build for his/her high school (500 words, with sketch, diagram, photo or prototype, if desired): (Send as attachment)

Name of Suggested High School Teacher (Last, First, Middle) Name and Contact Information/ Address of High School Sex Home Address Department Birthdate Highest degree earned Age Contact details Landline: Mobile: E-mail:

Promissory Note: If accepted in the VISSER Summer Workshop Program, I promise that I would commit myself to the project that I will work on and I will finish the 2-week program. _________________________ _________________________________ Name & Signature of Applicant High School Teacher _________________________________ Name & Signature of Parent of Applicant

Name & Signature of

OVPAA-SWP Form 1.0_ver1_04202012