The Genius Lab – Online Registration
Imani Community Development Hands-on STEM for Camden Youth (Ages 7–18) Please complete this form to register your child for The Genius Lab. Space is limited to 10–15 participants.
Participant Information
Participant Full Name
*
First Name
Last Name
Preferred Name (if different)
Date of Birth
-
Month
-
Day
Year
Date
Age
Grade Level
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
Other
School Attending
Parent / Guardian Information
Parent / Guardian Full Name
*
First Name
Last Name
Relationship to Participant
Please Select
Parent
Guardian
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Communication
Phone
Email
Text Message
The Genius Lab meets:
• Wednesdays, 5:00–7:00 PM
• Saturdays, 10:00 AM–12:00 PM
• February–May (school-year sessions)
Each session includes:
• Free Lab Exploration
• Guided STEM Instruction (Robotics, Coding, Electronics, Physics, Rocketry, 3-D Design)
• Fellowship and a healthful meal
I understand and agree to the program schedule and structure
*
I agree
STEM Experience
Has your child participated in a STEM program before?
Yes
No
If yes, please briefly describe
Areas of Interest (select all that apply)
Robotics
Coding
Electronics
Physics
Rocketry
3-D Design & Printing
Not sure yet
Health & Dietary Information
Does your child have any allergies, medical needs, or dietary restrictions?
No
Yes
If yes, please explain
Submit Registration
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