2021 Challenger Virtual Programs Registration Form

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* 1. Parent/Guardian Name (First, Last)

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* 2. Student’s Name (First, Last)

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* 3. Grade

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* 4. Age:

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* 5. Gender

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* 6. Contact Information

Mailing Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 7. Program Name

Challenger Virtual Program

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* 8. Grade Groups

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* 9. Class Date(s)

February 16, 2021 - Our Solar System 3-5 Grade

February 16, 2021 - Navigation By the Stars 6-8 Grade

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* 10. Emergency Contact (First, Last)

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* 11. Phone

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* 12. Ethnic/Race (optional, for grant purposes only):

Medical Information

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* 13. Does student have any physical, mental, or psychological conditions?

No

Yes (please specify)