Code Xero Course - STEMWorks Registration Form

FREE Coding and App Building Course STEMWorks Registration Form
Hello Family!

This summer we will be offering a FREE course called Code XERO. This is our very first Virtual Summer Coding and Mobile App Building course for students ages 10-19. Throughout the 4-week summer course students will be able to dive deeper into the foundation of coding and gain a chance to make their OWN MOBILE APP.

Students will join course facilitators on Zoom every Tuesdays and Thursdays afternoon from 1:00pm - 2:30pm starting July 27th! The final session will take place on August 19th.

Spaces are limited and registration closes on July 23rd

Sign up TODAY!

If you are not a member of our STEMWorks community, that's okay too. We are offering this FREE course to all youth ages 10-19. Please fill out the information below to register a student within this course.
How did you hear about the Coding and App Building Course? (Select all that apply.) *

Social Media From a Friend From a Community Member Google Search Received an email from Black Physicians of Tomorrow From the organization's website Other
Participant's Information
Participant's Name *

First Name Last Name
Participant's Age *
Grade Level *
Indicate the grade you recently completed this year.
Parent/Guardian's Information
Parent/Guardian's Name *

First Name Last Name
Parent/Guardian's Phone Number *
Please enter a valid phone number.
Parent/Guardian's Email *
example@example.com
What is your preferred method of communication? *

Phone call Text Email Other
Online Programming Requirements and Considerations

In order to understand how each student will be connecting online with the course facilitators, please read and complete the following questions below. Participants will also need an email to connect with us on Google Meets/Zoom. By providing your child's email, you are consenting to email communications to the participant. Parents/Guardians will be CC'd on all emails.
Participant's email? *
example@example.com
Does the participant have a reliable laptop with a webcam and microphone they can use during the course regularly? *

Yes No Sometimes
Do you foresee any other barriers that would affect the participant from engaging online? *

Access to Internet Lack of quiet space to log on Not comfortable with online format None Other
Please explain.
This is a 4-week summer course that will take place Tuesdays and Thursdays from 1:00pm - 2:30pm starting July 27th - August 19th. Can you indicate below if student participant will be available to attend these dates and times throughout the course? (Please choose the most appropriate option below) *

Yes, I confirm participant will be able to attend those dates and times. Yes, I confirm will be able to attend SOME of those dates and times. No, I do not confirm participant will be able to attend any of those dates and times.
Attendance for each session will be taken. Only student participants who are able to attend at least SIX(6) sessions out of the eight(8) sessions offered in the course - a 75% attendance rate - will be awarded with a gift. Could you please select the type of gift the participant would like to receive? *

Gift card to Amazon Gift card to Best Buy/the Source Gift card to EB Games Pre-paid Visa Gift card
Terms and Conditions
The parent/guardian should supervise the participant if needed for the virtual activities. For participants below 13 years old, the parent/guardian will be responsible for handling, maintaining, and supervising their accounts. Most virtual sessions of the course will be recorded so by signing this form, you agree for the participant to be recorded for archive and promotional offers only. All the lessons and activities will be recorded so that the participant can rewatch them if needed. Please avoid absences because the slot is already resolved for the participant. The video conferencing app that will be used is via Zoom. If an issue occurs, the next app to use will be Google Meets. Kindly make sure that all requirements are available to fully enjoy the virtual summer coding course.
Parent/Guardian Signature

Clear
Date Signed

Month Day Year
Date
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FREE Coding and App Building Course STEMWorks Registration Form

Hello Family!

Participant's Information

Parent/Guardian's Information

Online Programming Requirements and Considerations

Terms and Conditions