Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

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Student Name *

First Name

Last Name

Student’s Current Level of STEM Training

Beginner – New to tech

Intermediate – Some school-based exposure

Advanced – Participated in previous STEM/tech programs

Student Interests (Check all that apply)

All data is confidential and will be used only in our final impact report and to improve programming.

Coding

Gaming

Drone Technology

AI

Agriculture/Farming

Working at a Grocery/Restaurant

Playing a sport for a school or club team

Practicing religion or faith belief