PDX Cyber Camp Registration
Please fill this out to submit your application to the camp. Your application will not be considered without a matching teacher recommendation sent into pdxcyber@gmail.com
Last Name of Student
Your answer
First Name of Student
Your answer
What grade will the student be in the fall?
Name of school the student currently attends
Your answer
Email of Student (We will send emails to this account)
Your answer
Gender of Student
Does the student qualify as an under-represented minority in the technology field? (as defined here: http://www.nacme.org/underrepresented-minorities)
Will the student apply for a camp scholarship based on financial need?
Last Name of Parent/Guardian
Your answer
First Name of Parent/Guardian
Your answer
Email of Parent/Guardian (emails will be sent to this account as well as student)
Your answer
Primary phone number
Your answer
Home Address
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
Allergies or Other Medical Concerns
Your answer
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