Glenns Campus STEM Academy Registration
STEM Camp:
June 8, 2019
9:00AM - 12:30PM
Limited Capacity: 40
Registration ends June 1, 2019 or when capacity is reached
Email address *
Participant Registration Information
Student Name: *
First Name, Last Name
Your answer
Grade entering in 2019-2020: *
Your answer
Circle One: *
Date of Birth *
MM
/
DD
/
YYYY
Student Ethnicity: *
Phone (home) *
(804)xxx-xxxx
Your answer
Alternate Phone (Cell)/ Daytime Phone
(804)xxx-xxxx
Your answer
Email Address:
Your answer
Home Address:
Your answer
How did you hear about the Summer STEM Academy? *
Check all that apply
Required
Emergency Contacts:
In case an emergency arises, contact:
Name, Relation to Student and Phone: Please provide two *
First Name, Last Name/ Relation to Student/ Phone
Your answer
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