2026 STEM Camp Application

2026 STEM Camp Application

June 1–5, 2026 • Grades 7–12 | Applications must be received by May 18, 2026. Participants must have transportation to and from Coahoma Community College.
Camper and Primary Contact Information
Name of Student*

First NameLast Name
Gender
Date of Birth*

MonthDayYear
Date
Age (at the time of Camp)*
Name of School (Current)*
Grade (Current)*
T-Shirt Size (Adult)*
Parent/Guardian Information
Name of Parent/Guardian/Primary Contact*
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email address you check frequently*
example@example.com
Best way to contact you?*
Emergency Contacts

Please provide two additional people, different from the parent/guardian listed above, who would automatically be contacted if the parent can’t be reached.
First Emergency Contact Name*
First Emergency Contact Relationship*
First Emergency Contact Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
First Emergency Contact Work/Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
First Emergency Contact Phone Extension
Second Emergency Contact Name*
Second Emergency Contact Relationship*
Second Emergency Contact Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Second Emergency Contact Work/Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Second Emergency Contact Phone Extension
Medical/Special Needs
Medical conditions, allergies, food allergies, or special needs
Program Participation
Are you a participant in Educational Talent Search (TRIO)?*

YesNo
Should be Empty:

2026 STEM Camp Application

Camper and Primary Contact Information

Parent/Guardian Information

Emergency Contacts

Medical/Special Needs

Program Participation