Summer Bridge 2020 Registration Form

Student Information

Student's Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

Home Address *

Street Address

Apt #

City State / Province

Postal / Zip Code Country

Birth Date *

Month Day Year

Gender *

Male Female Do not Respond

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 N/A

Do you live or attend school in Northern Manhattan? *

Yes No

Course Selection

Which Course are you applying for? *

Algebra I English ELA/ESL Enrichment

Do you plan to be absent more than twice? *

Yes No

Education Information

Student ID OSIS#

Osis # can be located in the back of your student ID card

Current Grade *

STEM Institute Summer Bridge Program is for Rising 9th Graders only.

Your Current Middle School Name & Address *

Middle School Name

Middle School- Street Address

City State / Province

Postal / Zip Code Country

Your Guidance Counselor Name? *

Your Counselor email address *

example@example.com

Name the High-School you will attend in September 2020:

Parent/Guardian Information Must be Filled out by Parent or Guardian

Name *

First Name Last Name

Cell Number *

Area Code Phone Number

Home 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 STEM Institute during the Summer Bridge 2020 program. from June 29, 2020 - August 6, 2020 ; Mondays - Thursdays 9:00AM - 12:00PM

PROGRAM DISCLOSURE ABOUT COVID-19

** Based on states of Covid-19 Outbreak all STEM Institute Summer programs may totally or partially be given online ** Students & Parents will be notified accordingly in any changes or resolutions taken. We thank you for your flexibility at this time and look forward to work with you during the Summer!

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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STEM Institute Summer Bridge Program 2020 Application