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* 1. Name of Student (First and Last)

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* 2. Student's e-mail address (or parent's email if student does not have one)

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* 3. Best Contact Phone Number for Student

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* 4. Parent’s Name

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* 5. Best Contact Phone Number for Parent

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* 6. Parent's Email Address

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* 7. Choose your age

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* 8. Please write the name of your middle school or high school

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* 12. If yes, what is his/her name?

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* 13. What is your primary disability?  If you have more than one, please list the primary followed by the others.

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* 15. If other, please specify:

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* 16. What are your top 3 career choices?

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* 17. What do you hope to get out of this
week?

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* 19. Do you have access to a computer?

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* 20. Are you allowed to install software on your computer?

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* 21. Do you have an inkjet printer to print projects? You will be required to print approximately 15 sheets. The kit will provide the paper you need.

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* 23. Do you require one on one instruction?

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* 24. Do you require some help and instruction?

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* 25. Can you work independently on projects?

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* 26. Do you have high-speed internet?

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* 27. Do you have a Gmail account? If not, you will need to set one up to use Google Classroom.

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* 28. Can you use sharp scissors? The STEM camp kit will contain this item.

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* 29. Do you have an iron and can you use it safely?

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* 30. Can you use E6000 glue? It is a petroleum-based glue for plastics and has an odor.

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* 31. What is your physical address?

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