2018 Summer STEM Camp Registration
1.
Name of Student (First and Last)
2.
Student's e-mail address (or parent's email if student does not have one)
3.
Best Contact Phone Number for Student
4.
Parent’s Name
5.
Best Contact Phone Number for Parent
6.
Parent's Email Address
7.
Choose your age
14
15
16
17
18
8.
Please write the name of your middle school or high school
9.
Do you have a disability?
Yes
No
10.
Are you currently on an Individualized Education Program (IEP) or a 504 Plan
at your school?
Yes
No
11.
Do you have a VR Counselor?
Yes
No
12.
If yes, what is his/her name?
13.
What is your primary disability? If you have more than one, please list the primary followed by the others.
14.
Do you require any learning accommodations or accessible materials?
Yes
No
15.
If other, please specify:
16.
What are your top 3 career choices?
17.
What do you hope to get out of this
week?
18.
T-Shirt Size:
Small
Medium
Large
X-Large
XX-Large
XXX-Large
XXXX-Large
19.
Do you have any food allergies? If so, please describe those allergies.
20.
What, if any, special dietary needs do you have?
Current Progress,
0 of 20 answered