After-School Credit Bearing Program -Spring 2021

FREE Online After-School Credit Bearing Program FEBRUARY 1ST, 2021 - JUNE 3RD, 2021

Available Courses for Grades: 9-12; Mondays & Wednesdays, or Tuesdays & Thursdays from 5:00 PM- 7:00PM
Student Information
Student's Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Home Number

Area Code Phone Number
Home Address *

Street Address

Apt #

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
Gender *

Male Female Do not Respond Other
Ethnicity *

Black Non-Hispanic Hispanic White Non-Hispanic American Indian Asian-Pacific Islander
Primary Language *

English Spanish French
Have you attended the STEM Institute program before? *

Yes No
If Yes, which program did you attend? *

SHSAT Prep Program After-School Program Saturday Program Summer Bridge Summer Institute Other N/A
Do you live or attend school in Northern Manhattan? *

Yes No
Education Information
Student's Guidance Counselor Name
Guidance Counselor Email
example@example.com
GWEC - Student High School Name *

High School for Media and Communications The College Academy High School for Health Careers and Sciences High School for Law and Public Service Not Listed
Your Current High School Name & Address *

High- School Name

High- School- Street Address

City State / Province

Postal / Zip Code
Student ID OSIS#
Osis # can be located in the back of your student ID card
Student's Current Grade Level ? *

9 10 11 12
Available Courses - Each Class grants an equivalent HS credit. (select up to 2)
Did you previously take and Pass Algebra I? *

Yes No
Please select which Math Course do you want to register for? *

Algebra II Mondays & Wednesdays 5:00PM- 7:00PM Geometry Mondays & Wednesdays 5:00PM - 7:00PM Not Math - registering for a science course only.
Please select which Science Course do you want to register for? *

Living Environment Tuesdays & Thursdays 5:00PM -7:00PM General Chemistry Tuesdays & Thursdays 5:00PM - 7:00PM
Please indicate if you received an NX grade in any of the courses listed? *

Yes in Algebra II Yes in Geometry Yes in Chemistry Yes in Living Environment Not Applicable. (First time taking the class)
Do you understand that you cannot be absent more than three (3) times during the program? *

Yes No
🚨🚨🚨🚨🚨SORRY, THE AFTER-SCHOOL CREDIT BEARING PROGRAM DOES NOT ALLOW STUDENTS TO HAVE MORE THAN 3 UNEXCUSED ABSENCES!!! 🚨🚨🚨🚨🚨
Parent/Guardian Information Must be Filled out by Parent or Guardian
Name *

First Name Last Name
Cell Number *

Area Code Phone Number
Parent E-mail *
Occupation
How did you hear about us? *

School Friend Social Media Flyer Internet
Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Does the Student have any allergies, chronic illness, or medical conditions that require accommodation? If yes, please describe. *
Media Release and Authorization

I hereby consent for my child to participate in interviews, the take of photographs and videos for educational purposes. I also grant the STEM Institute, the right to edit, use and reuse such products for non-profit purposes including use in print, on the internet and all other forms of media. I also hereby release the New York City Department of Education and its agents and employees from all claims, demands and liabilities whatsoever in connection with the above.
Parents Initials *
If consenting to the Media Release form please place your initials
Parental Permission

I hereby give my approval for my child’s participation in any and all activities prepared by the STEM Institute during the After-School High School 2021 program from February 1, 2021 - June 3, 2021.

PROGRAM DISCLOSURE ABOUT COVID-19

** Based on the status of the Covid-19 Outbreak, all STEM Institute programs may totally or partially be given online for the duration of the program** Students and Parents will be notified accordingly in any changes or resolutions taken. We thank you for your flexibility at this time and look forward to working with your child in this academic cycle!
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Student Registration Photo
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FREE Online After-School Credit Bearing Program FEBRUARY 1ST, 2021 - JUNE 3RD, 2021