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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
Email address *
Participant Registration Information
Student Name: *
First Name, Last Name
Circle One: *
Date of Birth *
MM
/
DD
/
YYYY
Student Ethnicity: *
Phone (home)
(804)xxx-xxxx
Alternate Phone (Cell)/ Daytime Phone
(804)xxx-xxxx
Email Address:
Home Address:
How did you hear about the Summer STEM Academy? *
Check all that apply
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
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