Young Women In Science STEM Summer Survey 2019
For female-identified youth entering grades 4-6

Dates: August 5th- August 9th, 2019
Location: Berkshire Community College
Time: 9:00 am- 3:30 pm
Cost: $300

Please note: This form may only be used to register one child at a time.

Applicant Info
Child First Name *
Your answer
Child Last Name *
Your answer
Date of Birth *
Please use format month/day/year
Your answer
School *
Select a School
Grade *
Grade completed as of end of previous school year.
Science Teacher *
Your answer
Has your child participated in a Flying Cloud Insititute program before? *
If yes, in which program(s)?
If no, how did you hear about this program? *
Parent/Guardian Info
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Email Address *
Enrollment confirmation and payment information will be sent to this address.
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone *
Your answer
Cell Phone
Your answer
Work Phone
Your answer
Medical Information
Please answer all questions below.
Does your child have asthma? *
If yes, does your child use an inhaler?
Does your child have any allergies? *
If yes, what allergies?
Your answer
If yes, does your child carry an EpiPen?
Does your child take any medication the Flying Cloud Institute staff should be aware of? *
If yes, what medication(s)?
Your answer
Does your child have any learning or social challenges the Flying Cloud Institute staff should be aware of? *
If yes, please use this space for a description of the challenge(s) and best ways to address if necessary.
Your answer
Permission to Participate *
I give permission for photos, video or artwork of or by my child to be used for promotional material by FCI. *
Registration Requirements

1. Why do you want to participate in this program? Specifically addressing the following points:

- Why do you love science, technology, engineering and math?
- How do you think this program will effect your plans for the future?
- What sets you apart from your peers?

sent or emailed to the address below.

Flying Cloud Institute
St James Place
352 Main Street Ste. 212
Great Barrington, Ma 01230

Program Cost: $250
Please make checks payable to Flying Cloud Institute, include your child or children's names in the memo, and remit to:

Flying Cloud Institute
St James Place
352 Main Street Ste. 212
Great Barrington, Ma 01230


Financial Aid
Financial Aid Participants who apply for financial aid will have their spots held until the application is processed and their award decision has been made. Please complete the form on our website,
Are you interested in sponsoring a scholarship student? *
* Please indicate below if you are interested in giving a full or partial scholarship. By indicating yes, you will receive more information about our sponsorship program
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