Registration Form
Weekend STEM Club
Member Information
Girl's Name
Date of Birth
/
Month
/
Day
Year
Date
Age
School
Grade
T-shirt Size
Girl's email address if applicable
example@example.com
Girl's phone number (if applicable)
Parent/Guardian’s Name
Address
City
State
Zip Code
Parent/Guardian’s email address
example@example.com
Parent/Guardian’s phone numberr
Emergency Contact Name
Emergency Contact Phone Number
What is the ethnicity/race of the girl participating (check all that apply):
Alaskan Native/Native American
African American/Black
Asian
Caucasian/White
Hawaiian?Pacific Islander
Latino/Hispanic
Other (Please Define)
What languages is spoken in your home?
English
Spanish
Other
Who lives with the participant at home? Please check one box only:
Both Parents
Mother Only
Neither parent (describe below)
Father Only
One Parent at a Time (Joint Custody)
Neither Parent
Is the Head of Household a female?
Yes
No
How many people are in the household?
Is someone in the household currently receiving: check all that apply
Food Stamps
TANF
Medicaid
SSDI
SSI
Free/Reduced School Lunch
Please provide your income level:
$0 – $10,000
$10,001 – $20,000
$20,001 – $30,000
$30,001 – $50,000
Over $50,001
Parent/Guardian’s Signature
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: