STEMWorks Program Application Form
Due to the ongoing COVID-19 pandemic, the 2020-2021 STEMWorks Program will be completely virtual until further notice. Students will be connecting online using Google meets and Learn Cube, an online platform where students will have access to new features that can be used to connect with their tutor online. A program calendar will be sent to all participants. which will include important dates for program closure, STEM Workshops, etc. Limited spots are available! Students will be notified if they are waitlisted.
Orientation: November 13th 2021 | First Tutoring Session: November 20th, 2021
Online Tutoring and Workshops every Saturday 10am - 12pm (except for holidays)
I am a...
*
Parent/Guardian
STEMWorks Volunteer/Tutor
Student
Choose the best option that applies to you, the person who is filling out this form.
Is this application for a first-time or returning STEMWorks Program Participant
*
First-time participant
Returning participant
How did you first hear about the program? (select all that apply.)
Social Media
News Outlet
Through a School
From Friend
From a Community Member/Event
Google Search
Flyer/Poster
Received an E-mail from Black Physicians of Tomorrow
Black Physicians of Tomorrow Pop-up Booth
Other
Participant Information
Participant Name
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First Name
Middle Name
Last Name
Gender
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Male
Female
Other
Birth Date
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Please select a month
January
February
March
April
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November
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Month
Please select a day
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Day
Please select a year
2024
2023
2022
2021
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Year
Age
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Grade Level
*
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Due to limited resources, only students ages 12-19 enrolled in the STEMWorks Program will receive online tutoring support at this time. All other workshops or events will be open to students younger than 12 years old.
Name of School
*
Please put your full school name here (Example: Dunbarton High School)
City/Town of your School
*
Example: Pickering, Ajax, Whitby, Oshawa, etc.
School Board
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Durham District School Board
Durham Catholic District School Board
Toronto District School Board
Other
T-shirt Size
*
XS
S
M
L
XL
Is this participant enrolled in any other program(s)?
Yes
No
Race/Ethnicity of Participant (please set all that apply.)
*
Indigenous (First Nations, Métis, Inuit)
Black (e.g. African, Caribbean, North American, Afro-Latin American)
East Asian (e.g. Korean, Japanese, Chinese)
Indo-Caribbean (e.g. Guyanese, Trinidadian)
Latin American (e.g. Colombian, Ecuadorian, Chilean)
Middle Eastern (e.g. Iranian, Syrian, Iraqi, Lebanese)
South Asian (e.g. Indian, Pakistani, Sri Lankan)
Southeast Asian (e.g. Filipino, Vietnamese, Cambodian)
White/Caucasian
Unknown
Other
Prefer not to say
If 'Other', please specify.
How will your child be logging onto Learn Cube/Google Meets for online program sessions?
*
They will be logging onto Learn Cube/Google Meets on their own
I will be supporting them in logging on
Other
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Residence & Contact Information
Address
*
Street Address
Apartment/ Unit Number
City
Province
Postal
Phone Number
*
-
Area Code
Phone Number
Parent/Guardian Information
Name
*
First Name
Last Name
Email
*
Confirmation Email
Confirm Email
Mobile Number
*
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
What is your preferred method of communication?
Email
Phone call
Text
Other
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Relation to Participant
*
Emergency Contact Number
*
-
Area Code
Phone Number
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Online Programming Considerations
In order for us to understand how each student will be connecting with tutors online, we would like to understand the current resources, access and experiences each family will be navigating at this time. Participants will 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.
Does your child have a reliable laptop with a webcam and microphone they can use to attend the program regularly?
*
Yes
No
Sometimes
Do you foresee any other barriers that would affect your child from engaging online?
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Access to Internet
Lack of quiet space to log on
Not comfortable with online format
Other
None
Please explain.
What is the best way to get in contact with your child?
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Email (we will CC parents/guardians on emails to participants)
Phone call
Other
What is your child's email?
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Confirmation Email
ex:name@example.com
Is your child attending school in-person or online?
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In-person
Online
Other
What have been your challenges or concerns related to your child returning back to school this year? (Select all that apply.)
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COVID-19 Safety
Quality of Learning
Workload
Online Format
Mental Health
Grades and Academic Achieve
Loss of Social Interaction
Loss of Extracurriculars
Limited Resources
Limited Access to Academic Support
Other
None
Prefer not to say
Please explain.
(If you don't have an explanation for this section, please put NA)
What have been your challenges or concerns outside of your child's schooling?
Do you have any additional questions or concerns about the STEMWorks program this year?
We will do our best to get back to you concerning any questions you may share with us at this time.
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Consent & Liability
Please select ONE of the following options below to give your consent.
Terms and Conditions (Accepted)
Terms and Conditions (Not Accepted)
Submit
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