Registration Information

The following information will be needed to complete this registration form:

School Information:
  • Contact information for person completing this form, secondary contact, and Certifying Principal.
  • Name of the school in which the Certifying Principal serves
  • Name of Public School District in which the school operates 
  • Name of Educational Service Cooperative area in which the district operates (does not apply for districts in Pulaski County)
  • School Email Address of Certifying Principal/Delegate
  • Current school year's Fall Cycle 2 combined enrollment of students in all ADE/ARCareerEd approved high school computer science courses named here: https://goo.gl/ttwBpu for the school in which the team is based (does not apply for homeschool teams)
Team Member Information:
  • Full Legal Name of each team member
  • Preferred Name for Certificate(s)/Award(s)
  • Date of Birth of each team member
  • Email addresses for each ADULT team member
  • Name and email addresses for parent or guardian of each MINOR team member
  • If the team member or his/her guardian is requesting an accommodation as allowed within a documented IDEA Individualized Education Program or 504 plan and what that requested accommodation is
  • Home school team members will need to submit documentation demonstrating Arkansas residency for all team members and at least one team member must reside in the Certifying Principal's school zone
Primary Contact Information

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* 1. First and last name of person completing this form

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* 2. Title and organization of person completing this form

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* 3. School email address of person completing this form

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* 4. School phone number of person completing this form

Secondary Contact Information

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* 5. First and last name of secondary contact (cannot be principal or primary contact)

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* 6. Title and organization of secondary contact

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* 7. School email address of secondary contact

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* 8. School phone number of secondary contact

Certification Information

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* 9. First and last name of Certifying Principal

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* 10. School email address of Certifying Principal

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* 11. School phone number of Certifying Principal

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* 12. Name of the school in which the Certifying Principal/Delegate serves

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* 13. Name of public school district in which the certifying school (public or private) operates

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* 14. Educational Service Cooperative area in which the certifying school (public or private) operates

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* 15. LEA# of public school district area in which the certifying school (public or private) operates (may be located at https://adedata.arkansas.gov/spd/Home/districts)

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* 16. Please indicate the combined number of students enrolled in all ADE/ARCareerEd approved high school computer science courses named here: https://goo.gl/ttwBpu for the school in which the team is based (does not apply for home school teams). For public schools, these should match these numbers submitted within the school's Cycle 2 Report. Private schools may be required to submit supporting documentation for responses provided.

Team Information

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* 17. Is this team a public school team, private school team, or home school team?

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* 18. If the team is being registered as a homeschool team, I acknowledge that at least one of the three team members I am certifying as part of this team lives within the boundaries of my school and based on their confirmed address would be eligible to attend my school.

Team Member 1 Information

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* 19. First Name of this Team Member

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* 20. Middle Name of this Team Member

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* 21. Last Name of this Team Member

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* 22. Preferred FULL name to be printed on certificate(s)/award(s) ... Please enter name in First Middle (if applicable) Last if applicable (Ex. John Doe Smith)

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* 23. On 02/26/2021, will this team member be a legal adult or a legal minor?

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* 24. Email Contact Information for this Team Member

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* 25. Is this team member or his/her guardian is requesting an accommodation as allowed within a documented IDEA Individualized Education Program or 504 plan?

Team Member 2 Information

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* 26. First Name of this Team Member

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* 27. Middle Name of this Team Member

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* 28. Last Name of this Team Member

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* 29. Preferred FULL name to be printed on certificate(s)/award(s) ... Please enter name in First Middle (if applicable) Last if applicable (Ex. John Doe Smith)

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* 30. On 02/26/2021, will this team member be a legal adult or a legal minor?

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* 31. Email Contact Information for this Team Member

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* 32. Is this team member or his/her guardian is requesting an accommodation as allowed within a documented IDEA Individualized Education Program or 504 plan?

Team Member 3 Information

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* 33. First Name of this Team Member

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* 34. Middle Name of this Team Member

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* 35. Last Name of this Team Member

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* 36. Preferred FULL name to be printed on certificate(s)/award(s) ... Please enter name in First Middle (if applicable) Last if applicable (Ex. John Doe Smith)

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* 37. On 02/26/2021, will this team member be a legal adult or a legal minor?

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* 38. Email Contact Information for this Team Member

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* 39. Is this team member or his/her guardian is requesting an accommodation as allowed within a documented IDEA Individualized Education Program or 504 plan?

Completion

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* 40. Submission is NOT a confirmation of receipt or that a team is registered. I also understand that I must bring the required consent forms to the Regional Event. If the Regional Event is shifted to a digital format instructions will be sent at that time on how to submit the forms digitally.

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