PROGRAM ENROLLMENT FORM

PROGRAM ENROLLMENT FORM
SECTION I
APPLICANT INFORMATION
Applicant Name

Applicant First NameApplicant Last Name
Applicant Date of Birth

MonthDayYear
Date
Applicant Gender
Applicant Nickname
APPLICANT ADDRESS
Applicant Address

Applicant Street Address

Applicant Street Address Line 2

Applicant CityApplicant State

Applicant Zip Code
APPLICANT CONTACT INFORMATION
Applicant Email
example@example.com
Applicant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Phone Type
SECTION II
PARENT/GUARDIAN CONTACT INFORMATION 1 (REQUIRED FOR APPLICANTS UNDER 18)
PARENT/GUARDIAN 1 Name

PARENT/GUARDIAN First NamePARENT/GUARDIAN Last Name
PARENT/GUARDIAN 1 Email 1
example@example.com
PARENT/GUARDIAN 1 Phone 1
Format: (000) 000-0000.
PARENT/GUARDIAN 1 Phone 2
Format: (000) 000-0000.
PARENT/GUARDIAN 1 Email 2
example@example.com
Address is same as Learner
Parent Guardian 1 Address

Street Address

Street Address Line 2

CityState

Zip Code
PARENT/GUARDIAN CONTACT INFORMATION 2
Would you also like to add additional Parent/Guardian
PARENT/GUARDIAN 2 Name

First NameLast Name
PARENT/GUARDIAN 2 Email 1
example@example.com
PARENT/GUARDIAN 2 Phone 1
Format: (000) 000-0000.
PARENT/GUARDIAN 2 Phone 2
Format: (000) 000-0000.
PARENT/GUARDIAN 2 Email 2
example@example.com
Address is same as Learner
PARENT/GUARDIAN 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECTION III
EMERGENCY CONTACT INFORMATION
Would you like to add emergency Contacts beyond who is already listed.
Emergency Contact 1 First Name
First
Emergency Contact 1 Last Name
Last
Emergency Contact 1 Phone Number
Emergency Contact 1 Phone #Format: (000) 000-0000.
Emergency Contact 1 Relationship
Emergency Contact 2 First Name
Emergency Contact 2 Last Name
Last
Emergency Contact 2 Phone Number
Format: (000) 000-0000.
Emergency Contact 2 Relationship
SECTION IV
HEALTH INFORMATION
Does the applicant have any allergies including food allergies
Specify Allergies
If yes, please specify
If yes, does the applicant travel with necessary medication:
Does the Applicant have asthma?
Disclaimer: Please note that we are not qualified to administer medication. It is the responsibility of the applicant or their guardian to ensure that all necessary medications are provided and taken as needed.
Other health concerns (if applicable)
SECTION V
DISMISSAL INFORMATION
DISMISSAL INFORMATION
PRIVACY NOTICE
STEM in the Rockaways is committed to protecting your personal information. All sensitive data will be kept confidential and used only for program purposes. For more information, please visit our Privacy Policy on our website.
MEDIA CONSENT AGREEMENT
By participating in programs and activities hosted by STEM in the Rockaways, you acknowledge and agree that photographs, videos, or audio recordings of participants may be taken during events or sessions. These media materials may be used by STEM in the Rockaways for promotional purposes, including but not limited to social media posts, emails, brochures, flyers, website content, and other marketing materials.

If you do not wish for your image or that of your child to be used for these purposes, please notify us in writing prior to participating in the program. STEM in the Rockaways respects your privacy and will ensure your preferences are honored.

By attending, you grant STEM in the Rockaways permission to use these materials for non- commercial purposes aimed at promoting and celebrating our programs.
PROGRAM CONSENT
Acknowledgment (For Applicants Over 18)
Acknowledgment (For Applicants Under 18)
Applicant/Parent/Guardian Signature
Signature Parent/Guardian By signing below, I affirm that all information provided in this application is accurate.
Applicant/Parent/Guardian Name
Applicant/Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

PROGRAM ENROLLMENT FORM

SECTION I

APPLICANT INFORMATION

APPLICANT ADDRESS

APPLICANT CONTACT INFORMATION

SECTION II

PARENT/GUARDIAN CONTACT INFORMATION 1 (REQUIRED FOR APPLICANTS UNDER 18)

PARENT/GUARDIAN CONTACT INFORMATION 2

SECTION III

EMERGENCY CONTACT INFORMATION

SECTION IV

HEALTH INFORMATION

SECTION V

DISMISSAL INFORMATION

PRIVACY NOTICE

MEDIA CONSENT AGREEMENT

PROGRAM CONSENT