2018-2019 STEMulates - Citywide NSBE Jr. Chapter
Student Last Name *
Your answer
Student First Name *
Your answer
Parent/Guardian Name *
Your answer
Email for Contact *
Your answer
Although STEMulates does not charge for the program, NSBE charges $5. Are you willing to cover the cost of the membership. If yes, please complete. If no, please stop and contact our staff to find another program for your student *
Will your student be in grades 3-12 in the 2018-2019 school year? If yes, please complete, if no, stop and contact our staff to find another program for your student *
Are you willing to participate on the 4th Saturday of each month? If yes, please complete. If no, please stop and contact our staff to find another program for your student. *
Racial/ethnic identity *
Gender Identity *
Birthday *
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Residency Status *
Current School Classification (beginning 2018-2019 school year) *
Anticipated Graduation Date
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GPA (on a 4.00 scale) *
Your answer
Anticipated Major *
Your answer
Anticipated 2nd Major *
Your answer
Did you complete an algebra class prior to high school? *
Are you interested in being mentored? *
Past Medical History (ex: Epilepsy, Asthma, etc.) *
Your answer
Any accommodations needed to participate in our program? *
Your answer
Any medications? *
Your answer
Known allergies (food, medications, environments, etc.) *
Your answer
Child's Physician (name and number) *
Your answer
Any other pertinent medication information? We are not responsible for any type of medical/ambulance costs. *
Your answer
Does your student have any behavioral issues of which our staff should be aware? *
If yes, explain
Your answer
I authorize The Gaskins Foundation and/or their authorized agent to release publicly my child's name, including pictures and videotape for use related specifically to their achievements. *
My student has permission to attend all of The Gaskins Foundation c/o Cincinnati STEMulates activities. We recognize that full participation in the program may requires the student to be transported by bus/van to various activities. In consideration of the child’s participation in the program, we will release and hold harmless Gaskins Foundation’s Cincinnati STEMulates, Whitney Gaskins, The University of Cincinnati and all of their employees, officers, directors, agents, members, insurers, and associates, from any and all claims, of any sort, type, nature, or description, whether known or unknown, foreseen or unforeseen, which could be asserted against any of the above-listed entities or persons, and they expressly waive any and all such claims. Said release and waiver shall not apply to bar claims for intentional or willful conduct. *
I give The Gaskins Foundation/STEMulates the permission to transport my child to the hospital in the event of an emergency as deemed necessary by the staff of The Gaskins Foundation c/o STEMulates *
Preferred Hospital (we will try our best to accommodate) *
Your answer
By enrolling into the Gaskins Foundation, I am showing my commitment to enhancing our student's future while making it enjoyable. I have read and full understand these policies and procedures. *
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