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{HER} Code Summer STEM Experience Interest Form
Hi there, please fill out and submit this form as soon as possible.
14
Questions
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1
Youth's Full Name
*
This field is required.
First Name
Last Name
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2
Youth's Age
*
This field is required.
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3
What race does the youth identify with?
*
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African American/Black
Asian
White American/Caucasian
Native Hawaiian and other Pacific Islander
American Indian and/or Alaskan Native
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4
Does the youth identify with Hispanic/Latino origins?
*
This field is required.
YES
NO
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5
How did you hear about the Summer Camp?
*
This field is required.
I received a flyer via email
Referred by CaseWorker
Child Protective Services
Visited RISE website
My Foster Agency
Other
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6
If you were referred by an individual such as a caseworker or agency please enter their Name, Title and Organization below.
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7
Will the youth require assistance with transportation to the camp?
*
This field is required.
YES
NO
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8
Is the youth currently experiencing or have a history of the following circumstances? (please select all that apply)
*
This field is required.
Currently in foster care/ kinship care/group home
Past CPS involvement of any kind
Family situation of homelessness or displacement
Family history of low income
Other
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9
Youth's Email Address
if applicable, WE DO NOT contact the youth without prior notice to the parent/legal guardian/foster parent.
example@example.com
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10
Youth's Phone Number
if applicable, WE DO NOT contact the youth without prior notice tot he parent/legal guardian/foster parent.
Area Code
Phone Number
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11
Name of person completing the form. ( If different from youth)
if different from the youth.
First Name
Last Name
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12
Your Phone Number (if different from youth)
Area Code
Phone Number
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13
Your Email Address (if different from youth)
example@example.com
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14
Image Field
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