FCF STEM 2023 Summer Camp Enrollment

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Please complete this form to register your child(ren) for the FCF STEM Summer Camp.

Email *

Child's Full Name (First, Middle & Last): *

Child's Date of Birth: *

YYYY

Child's Gender: *

Male

Female

Non-binary/Other

Prefer not to say

Required

Miami-Dade County Public Schools ID# (ALL STUDENTS ATTENDING PUBLIC OR CHARTER SCHOOLS SHOULD HAVE A SCHOOL ID ENTERED.)

No MDCPS ID#:

Not a student in MDCPS

Other:

Child's Current School: *

Is your child proficient in English? *

Yes

Required

Other language(s) spoken in your home? *

Spanish

Haitian Creole

None

Other:

Required

Street Address: *

City: *

Zip Code: *

Child's Ethnicity: *

Hispanic

Haitian

Other:

Required

Child's Race (select only one): *

American Indian or Alaskan

Asian

Black or African-American

Pacific Islander

White

Multiracial

Other:

Required

Child's Grade Level Completed : *

Sixth

Seventh

Eighth

Required

Does child have health insurance? (ex. private insurance, KidCare, Medicaid) *

Yes

Required

Please list any allergies: *

Child's Primary (Parent/Guardian) Caregiver Full Name: *

Primary (Parent/Guardian) Caregiver's Email Address:

Primary (Parent/Guardian) Caregiver's Phone Number: (all numbers no dashes i.e. 3334445555) *

Is this a cell/mobile phone?

Yes

We want to get to know your child better so that we can provide the best possible experience in our programs. Please tell us more about your child… What are the main ways in which your child communicates? (Mark all that apply) *

Speaks and is easily understood

Speaks but is difficult to understand

Uses communication devices like pictures or a board

Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking

Uses sign language

Uses sounds that are not words like laughing, crying or grunting

Required

What, if any, help does your child receive at this time? (Mark all that apply) *

Behavioral therapy or services

Counseling for emotional concerns

Daily medication (not including vitamins)

Occupational therapy (OT)

Physical therapy (PT)

Special education services in school

Speech/language therapy

None of the above

Required

What conditions does your child have that are expected to last for a year or more? (Mark all that apply) *

Autism spectrum disorder

Developmental delay (only if under age 5)

Intellectual/developmental disability (over age 5)

Hearing impairment or deaf

Learning disability (school age)

Medical condition or illness

Physical disability or impairment

Problems with aggression or temper

Problems with attention and hyperactivity (ADHD)

Problems with depression or anxiety

Speech or language condition

Visual impairment or blind

None of the above

Required

If you marked “None of the above” on the previous question, please skip the next two questions and sign below. If you marked any other answer on the question above, please answer the remaining questions and sign below. Do any of the conditions marked above make it harder for your child to do things that other children of the same age can do? *

Yes

Required

To support your child’s successful participation in this program, in what areas might s/he need extra assistance? *

No specific help needed

Holding a crayon/pencil, writing, using scissors or other fine motor tasks

Sports or physical activities like running or other gross motor tasks

Managing feelings and behavior

Academic, learning or reading activities

Adapting activities to take into account a visual or hearing impairment

Using assistive device(s) like a wheelchair, crutches, brace or walker

Personal services like help with feeding, toileting or changing clothes

Other:

Required

Please list any allergies:

Please tell us anything else you think it is important for us to know about your child:

Is your child on free or reduced lunch? *

Yes

Child's Shirt Size: *

Do you have additional children to register? *

Yes

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