Girls 4 Science Program Application - Malcolm X
PERSONAL INFORMATION
Site Location *
Are you a new participant? *
Are you a returning participant? *
Does returning student need a replacement T-shirt ? *
Select T-shirt size:
Quarter *
First Name *
Your answer
Last Name *
Your answer
Home Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Student Email Address
Your answer
Phone Number
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Ethnicity *
Check all that apply.
PARENTAL INFORMATION
First Name *
Your answer
Last Name *
Your answer
Language spoken at home:
Your answer
Click Here (if address is the same as the student).
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Work Phone # *
Your answer
Cell Phone # *
Your answer
Email address *
Your answer
What dates will participant not be able to attend?
Check all that apply.
EDUCATIONAL INFORMATION
What is your G.P.A.?
Your answer
What is your grade level? *
What was the last grade you received in reading?
Your answer
What was the last grade you received in math?
Your answer
What is your favorite subject?
Your answer
List your extra curricular activities.
Your answer
Please list your school name.
Your answer
Please list your school address.
Your answer
What is your school's zip code?
Your answer
EMERGENCY CONTACT INFORMATION
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Relationship *
Your answer
STUDENT PICK UP AUTHORIZATION
NO ONE WILL BE PERMITTED TO PICK UP YOUR CHILD IF THEIR NAME IS NOT LISTED BELOW. ALL PERSONS MUST HAVE AND SHOW THEIR PICTURE ID. MAKE SURE YOU LIST ALL ADULTS EVEN IF YOU RESIDE IN THE SAME HOUSEHOLD.
Please list the person other than parent/guardian authorized to pick up student.
List their first and last name.
Your answer
Please list the person other than parent/guardian authorized to pick up student.
List their first and last name.
Your answer
Please list the person other than parent/guardian authorized to pick up student.
List their first and last name.
Your answer
MEDICAL INFORMATION
Please list any allergies.
Your answer
Please list any medical or physical conditions.
Your answer
FOR NEW STUDENTS ONLY!
Please type a 100-word essay (double space) on why you want to participate in Girls 4 Science.
Your answer
RELEASE AUTHORIZATIONS
Please click on the links below and review the release forms. Please enter your name for each release to confirm your consent.
Emergency Waiver Release *
Click on this link to view this release: https://docs.google.com/a/girls4science.org/document/d/1eoXu4-o_tD5j_2_yTij2ha0GYx1Tn-xb1TP4rrjfOwM/edit?usp=sharing. Please type your name below to authorize your consent.
Your answer
Harmless Waiver Release *
Click on this link to view this release: https://docs.google.com/a/girls4science.org/document/d/1E_GCh31ySdgOgV0XBzDNW-VYCa0xnJbLpewdMYAoBkk/edit?usp=sharing. Please type your name below to authorize your consent.
Your answer
Photograph Consent and Waiver Release *
Click on this link to view this release: https://docs.google.com/a/girls4science.org/document/d/1DKP7btkd00IWeqC--VINIyJ-LZMohIbPSXeOZyquEos/edit?usp=sharing. Please type your name below to authorize your consent.
Your answer
Field Trip Permission Slip *
Parent or Guardian must sign if the participant is UNDER 18. Click on the link to view the permission slip. Then return to this section and type your name below. https://docs.google.com/a/girls4science.org/document/d/1m6fE0iLQW0-T73QfCtKbzuN9b2cXKhM6T4zC52ODRfk/edit?usp=sharing. Please type your name below to authorize your consent for the child referenced in this application.
Your answer
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