Shooting Stars - Tech Immersion Series

Name *

First Name Last Name

Email (Please list your personal email - not school associated email) *

example@example.com

Which session are you applying for? *

June 20th - July 15th 10:00 AM - 2:00 PM PST July 18th - August 12th 12:00 PM - 4:00 PM EST

Phone Number *

Please enter a valid phone number.

Home City *

Home State *

Home Zipcode *

School Name *

Rising Grade *

Age *

Please select the response that best represents your gender identity *

Male Female Non-Binary/non-conforming Other

Please select the response that best represents your racial identity *

Asian or Pacific Islander Black or African American Hispanic or Latino Native American or Alaskan Native White or Caucasian Multiracial or Biracial A race/ethnicity not listed here Decline to Answer

Parent Name *

Parent Phone Number *

Please enter a valid phone number.

Parent Email *

example@example.com

Please indicate your level of experience with any type of coding - remember, no experience is needed at all! *

1

2

3

4

5

1 is I have no experience with coding., 5 is I am very familiar with and comfortable with coding.

Have you participated in a coding or technology camp before? *

Yes No

What are your top 3 expectation from this camp? *

What kind of major do you want to take in college? *

Are you committed to spend the needed hours (Total 80 hours between July 11th and August 5th 2022) for this program? *

Yes No

How did you hear about this camp? (Organization, counselor, friends, family, WhatsApp, email list, social media, etc.) *

if you were referred by an organization, please name them here! *

Liability Waiver Accepted by Parent *

By saying yes below, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages, or which may hereafter occur to me as a result of participation in said event. This release is intended to discharge in advance Shooting Stars Foundation Inc, its officers, student and parent volunteers from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. I hereby give my consent to Shooting Stars Foundation to take photographs, video recordings, and/or sound recordings of me during my participation. I grant Shooting Stars Foundation my permission to use the negatives, prints, motion picture, video tapings, or any other reproduction of the same for promotional purposes on flyers, on the World Wide Web, or in any other manner deemed necessary. I expressly state that I have read, understand and am familiar with all provisions herein. I understand that this release is a contract and I sign it of my own free will. I agree to all terms and provisions herein.

Signed By (Participant Over 18, Parent, if Participant under 18)

Clear

Payment

USD Minimum donation is $499 but you are welcome to donate more if you so choose!

Shooting Stars - Tech Immersion - 2022 Application Form

Grades: Rising 8-12th grades in High School Students