7 Week STEM & Robotics Summer Enrichment Program
Students and Parents, please fill out all the required areas of the form.
First Name of Student
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Last Name of Student
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Students' Age as of June 1st 2016
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Student Date of Birth
MM
/
DD
/
YYYY
Student's Grade in 2016-2017 School Year
Name of Students School for 2016-2017, School Year
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Parent/ Guardian Full Name
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Parent/Guardian Email Address
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Parent/Guardian Contact Number
example: 513-000-0000
Your answer
Students Address
street number, street name, city, state
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Students Zip Code
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Students Gender
Are there any accommodations needed?
Example: wheelchair ramp etc.
Your answer
T-Shirt Size
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