Student Name *

First Name

Last Name

Date Of Birth

MM

DD

YYYY

Gender *

Female

Male

Trans

Non-Binary

Prefer Not to Answer

Race/Ethnic Background *

Black/African American

Black/Non-American

LatinX

Indigenous/First Nation

East Asian

South Asian

MENA - Middle Eastern North African

White/Caucasion

Student Phone *

Please provide a phone number that we can reach you at throughout the summer and afterwards.

(###)

###

####

Parent/Guardian Name *

First Name

Last Name

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Phone *

(###)

###

####

Emergency Contact (If different than above)

First Name

Last Name

Emergency Phone *

(###)

###

####

Do you have any food related allergies? *

* We will be offering snacks and would like to be aware of any allergies to lower the risk of an allergic reaction.

YES

NO

Do you have any non-food-related allergies (e.g., bee stings, environmental, etc.)? *

YES

NO

Do you have any dietary restrictions or preferences? (e.g., vegetarian, halal, gluten-free) *

YES

NO

Do you take any medications that you will need during program hours? *

YES

NO

Do you have any access requirements or accommodations you would like us to know about to support your participation in the program?: *

YES

NO