Student's Name* Elementary School* Parent/Guardian Name* Relationship to Student* MotherFatherGuardian Contact Information Parent/Guardian Phone* Parent/Guardian Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Recommendations List the names and emails of your math teacher, language arts teacher, and one additional teacher. Purcell Marian will send them the Cavalier Scholars Program Teacher Recommendation Form. Math* Teacher Name Teacher Email Language Arts* Teacher Name Teacher Email Additional Teacher* Teacher Name Teacher Email A piece of work that has made you proud. Submit one piece of work completed in the past year that you think is particularly strong and/or are most proud of. This could be an assignment for school, a piece of writing, artwork, etc. It should be accompanied by a brief statement (a paragraph) explaining what the work is, when and how you created it, and why you chose it. Acceptable formats are PDF (writing or visuals), JPG (photograph of a project or piece of art), or MP4 (video of a performance or large scale project). Upload the work below or email Bob Herring (bherring@purcellmarian.org) if the piece cannot be uploaded. Brief Explanation Upload Work Consent* Digital Signature
