GEMS & GISE ELECTRONIC REGISTRATION FORM
GIRLS IN ENGINEERING, MATH, AND SCIENCE and GUYS IN SCIENCE AND ENGINEERING
Meets Tuesday and Thursdays from 2:35-5:00pm. Classes begin the week of September 26, 2016 and continue through May 4th, 2017.
GEMS or GISE
chose one
Student Information:
First Name
Your answer
Student Information:
Last Name
Your answer
Grade:
Your answer
Date of Birth:
M/D/Y
Your answer
Student ID:
Your answer
Chose your attendance preference.
At the end of class my student will
*Bus transportation will be available only to students who have a regular school day bus assignment. Applications submitted after 9/12/16 will be accepted however bus transportation may not be available for first week of class.
Indicate student’s bus drop off address:
Your answer
Contact Information - Parent/Guardian 1:
First Name , Last Name
Your answer
Phone # Home:
Your answer
Work:
Your answer
Cell:
Your answer
Email address:
Email will be used for newsletters and to send out important program information
Your answer
Parent/Guardian 2:
First Name Last Name
Your answer
Phone # Home
Your answer
Work:
Your answer
Cell:
Your answer
Email address :
Email will be used for newsletters and to send out important program information
Your answer
Is there anything you would like to share about you child.
Allergies, special talents, etc.
Your answer
Attendance is important. We ask that you do not miss more than three sessions per semester. If you know that you will miss more than three days, it is recommended that you do not apply. A student with more than three unexcused absences will have a conference with the GEMS or GISE teacher to discuss the conflicts.
Your answer
Student Pledge of Commitment: I pledge I will attend class sessions, work hard with my group, cooperate, and be respectful of all participants and adults in the program and be a worthy Ambassador for the GEMS & GISE program at all public events. My electronic signature pledges my commitment to the goals of GEMS & GISE.
Student Signature _____________________ Date: ______________
Your answer
Parent/Guardian Consent: My student has my full support and consent to participate in the GEMS program. I have read over the material and pledge my effort to helping my student be successful in GEMS or GISE.

Parent/Guardian Signature _____________________Date _______________
Your answer
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