Summer Camp Registration – STEM³ Academy

Name

First Last

DOB

Age

Gender

School Name

Grade In September

Phone

Recent Teacher Name

First Last

Parent Guardian #1

First Last

Parent Guardian #1

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Parent Guardian #2

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Please list all siblings with age

Please select which camp(s) you are interested in having your child attend.

Valley Glen

Week 1: 6/15- 6/19 Engineering & Design
Week 2: 6/22- 6/26 Technology, Art & Design
Both Week 1 and Week 2

Irvine

Week 1: 6/22– 6/26 Engineering & Design
Week 2: 6/29- 7/2 (No class 7/3) Technology, Art & Design
Both Week 1 and Week 2

Culver City

Week 1: 8/3 – 8/7 Engineering & Design
Week 2: 8/10- 8/14 Technology, Art & Design
Both Week 1 and Week 2

What type of educational setting does your child attend?

Regular Ed/Inclusion
Special Education (part of day)
Special Education (full day)
Non-Public Special Ed School
Private School
Has a 1:1 aid at school

What other services is your child currently receiving?

Does your child have any specific diagnoses?

Yes
No

If YES, please list each diagnosis, when the child was diagnosed

Is your child on any medication?

Yes
No

If YES, Please list medications, dosage & time of administration.

Does your child have any allergies, medical restrictions or physical restrictions?

Yes
No

If YES, please explain.

Does your child have a history of seizures?

Yes
No

If YES, please explain.

Is your child on a restrictive diet (e.g. dairy free, gluten free)?

Yes
No

If YES, please explain.

Are there foods that your child will not eat? Are there specific food items that trigger behaviors?

What are your child’s main areas of interest and favorite activities?

What activities/tasks does your child NOT like to engage in or is restricted from participating in?

Please list your child’s strengths or special talents (e.g. music, art, building things)?

What are your goals for your child while they are involved with this program?

If you have any other information that you feel would be helpful to us, or that you would like us to know, please feel free to add you comments to the area below

How did you hear about the STEM3 Academy Summer Camp and Summer School program?

Consent*

I agree

“I authorize investigation of all statements contained in this Application to the program as may be necessary in arriving at an admission decision. In the event of admission, I understand that false or misleading information, given in the application of my child, or in any interviews, may result in rescission of any admission.”

Please select which camp(s) you are interested in having your child attend.

The Help Group

STEM³ Academy

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