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Summer 2017 STEM Academy Registration
STEM Camp: Code it, Create it, Command it!
Warsaw Campus only, Middle School Students 6-8
June 26-30, 2017
Limited Capacity: 28
Registration ends June 16, 2017 or when capacity is reached
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Email
*
Your email
Participant Registration Information
Student Name:
*
First Name, Last Name
Your answer
Circle One:
*
Male
Female
Date of Birth
*
MM
/
DD
/
YYYY
Student Ethnicity:
*
Choose
Hispanic/Latino
Asian
American Indians/Alaska Native
Black/African-American
White/Caucasian
Native Hawaiian/Other
Pacific Islander
Choose Not to Specify
Phone (home)
(804)xxx-xxxx
Your answer
Alternate Phone (Cell)/ Daytime Phone
(804)xxx-xxxx
Your answer
Email Address:
Your answer
Home Address:
Your answer
How did you hear about the Summer STEM Academy?
*
Check all that apply
RCC Website
RCC Facebook page
Middle School's Website
Middle School's Facebook page
Middle School Guidance Counselor
Middle School Newsletter
Middle School Flyer
Word of Mouth
Other:
Required
Emergency Contacts:
In case an emergency arises, contact:
Name, Relation to Student and Phone: Please provide two
First Name, Last Name/ Relation to Student/ Phone
Your answer
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