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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 these
three days?

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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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* 22. What level are your computer skills?

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* 23. Can you work independently on projects?

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* 24. Can you use sharp scissors? (The STEM camp kit will

contain this item).

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

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* 26. Can you use E6000 glue? (It is a petroleum-based glue

for plastics and has an odor).

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* 27. What is your physical mailing address?

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