Winter/Spring STEM Registration

Winter/Spring 2017 Participant Application

Ground Drone Assembly & Arduino Coding Thank you for your interest in the STEM enrichment programs presented through the partnership of S.T.E.M. Community Outreach and the Laurel-Jones County Library. To be considered for program participation, please complete all sections of the application, which includes a short answer questionnaire on back. Application submission deadline is Wednesday, January 10, 2018. Selected participants will be notified of selection on Friday, January 12, 2018, via phone and email. All questions regarding program details and application should be emailed to stemcommunityoutreach601@gmail.com

Program Information
Program of Choice (check one):*
- Grades 3-5 (Ages 8-11)
- Grades 6-8 (Ages 11-14)
Select preferred session for participation (check one):*
- Winter Session
- Spring Session
- Open to Either
Winter Session Dates
Grades 3-5: Tuesdays, Jan. 16 – Feb. 20 at 3:30-4:30pm
Grades 6-8: Thursdays, Jan. 18 – Feb. 22 at 3:30-4:30pm

Spring Session Dates
Grades 3-5: Tuesdays, March 20 – April 24 at 3:30-4:30pm
Grades 6-8: Thursdays, March 22 – April 26 at 3:30-4:30pm
Student Information
Student Name*
First Middle Last
School*
Grade Level*
Age*
Gender*
- Male
- Female
Ethnicity*
- African American
- Asian
- Caucasian
- Hispanic
- Native American
Family Type*
- 1-Parent
- 2-Parent
- Non-Traditional
Parent/Guardian Information
Name*
First Last
Gender*
- Male
- Female
Home Phone*
Cell Phone*
Work Phone*
Home Address*
Street Address Address Line 2 City ZIP / Postal Code
Email*
Other Parent/Guardian (if applicable)
Name
First Last
Gender
- Male
- Female
Home Phone
Cell Phone
Work Phone
Home Address
Street Address Address Line 2 City ZIP / Postal Code
Email
Household Info
Annual Family Income (will not be shared):*
- $0-$23,550
- $23,551-$74,500
- $74,501 and above
Household Size*
Signatures
Student Signature*
Please print name
Date*
Date Format: MM slash DD slash YYYY
Parent Signature*
Please print name
Date*
Date Format: MM slash DD slash YYYY
Short Essay Questions
INSTRUCTIONS: The questions below are designed to give us insight about your interest in science, technology, engineering, and math (STEM). Please use the space below to answer the following questions. Answers must be written in a neat and clear manner using complete sentences.
What to do want to become when you graduate from high school? Feel free to talk about college, military, or technical school plans.
How can learning about science, technology, engineering, and math (STEM) make you a better student?
List five words you think best describe you.
If you could invent something that would make life easier for people, what would you invent?

Winter/Spring 2017 Participant Application

Program Information

Student Information

Parent/Guardian Information

Other Parent/Guardian (if applicable)

Household Info

Signatures

Short Essay Questions

JCGHO Meeting

StoryTime PlayDate

Imagination Station

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