SHSAT Prep Application 2021

High-School & SHSAT Prep For Middle School Students in Grades 6th & 7th

🚨 6TH Graders Prep Starting in January 16, 2021; REGISTRATION CLOSED; 🚨 7TH Graders Prep Starting Saturday March 6, 2021. Saturdays 11:00 AM - 2:00 PM REGISTRATION CLOSES JAN 31,2021
Student Information
Student's Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Home Address *

Street Address

Apt #

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
Gender *

Male Female Do not Respond Other
Ethnicity *

Black Non-Hispanic Hispanic White Non-Hispanic American Indian Asian-Pacific Islander
Primary Language *

English Spanish French
Have you Attended the STEM Institute program before? *

Yes No
If Yes, Which program did you attend? *

After-School Program Saturday Program Summer Bridge Summer Institute Regents Prep Program N/A
Do you live or attend school in Northern Manhattan? *

Yes No
Education Information
Student ID OSIS# *
Osis # can be located in the back of your student ID card
Indicate the Student's Current Grade - Middle School Students ONLY in 6 or 7 grade *

6 7
***SORRY - THE REGISTRATION PERIOD FOR 6TH GRADERS IS CLOSED!! YOUR APPLICATION WON'T BE CONSIDERED***

ONLY 7TH GRADERS CAN REGISTER!!!!
Student's Guidance Counselor Name
Guidance Counselor Email
example@example.com
Your Current Middle School Name & Address *

Middle School Name

Middle School- Street Address

City State / Province

Postal / Zip Code
Are you currently Register in our Regents prep program? *

Yes No
Do you plan to be absent more than twice? *

Yes No
Would you like to be considered for our Regents Prep courses if your SHSAT application is not selected? *

Yes No
Which Regents Prep section would you like to be considered? *

Algebra, Tuesdays & Thursdays 4:00PM - 6:00PM Living Environment, Mondays & Wednesdays 4:00PM - 6:00PM Both Classes Mondays - Thursdays 4:00PM - 6:00PM
Parent/Guardian Information Must be Filled out by Parent or Guardian
Name *

First Name Last Name
Cell Number *

Area Code Phone Number
Parent E-mail *
Occupation
How did you hear about us? *

School Friend Social Media Flyer Internet
Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Does the Student have any allergies, chronic illness, or medical conditions that require accommodation? If yes, please describe. *
Does the student have and IEP or 504 that we should be aware of? *

Yes No
Media Release and Authorization

I hereby consent for my child to participate in interviews, the take of photographs and videos for educational purposes. I also grant the STEM Institute, the right to edit, use and reuse such products for non-profit purposes including use in print, on the internet and all other forms of media. I also hereby release the New York City Department of Education and its agents and employees from all claims, demands and liabilities whatsoever in connection with the above.
Parents Initials *
If consenting to the Media Release form please place your initials
Parental Permission

I hereby give my approval for my child’s participation in any and all activities prepared by the STEM Institute during the SHSAT Prep 2021 program. from January 16, 2021 - October 23, 2021*

🚨 PRIORITY SEATING WILL GO FOR STUDENTS IN COMMUNITY SCHOOL DISTRICT 6🚨

PROGRAM DISCLOSURE ABOUT COVID-19

** Based on states of the Covid-19 Outbreak all STEM Institute programs may totally or partially be given online for the whole program duration ** Students & Parents will be notified accordingly in any changes or resolutions taken. We thank you for your flexibility at this time and look forward to working with your child in this academic cycle!
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Student Registration Photo
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High-School & SHSAT Prep For Middle School Students in Grades 6th & 7th