Millhill STEM Summer Explorers Program

Contact & Personal Information

Student's Name*

First Last

What Trenton Middle School do you attend?*

Rivera Community School
Grace Dunn Middle School
Joyce Kilmer K-8 School
Hedgepath-Williams Middle School
Foundation Academy Middle School
STEM Civics Middle School

Who is your current science teacher?*

What do you like most about science and why?*

What science projects/experiments have you completed in school? Tell us about them.*

Have you participated in any science programs outside of your school? If so what did you like about them?*

If I asked your science teacher to tell me about you, what would your teacher say?*

What science TV shows or You Tube videos, if any, do you like to watch?*

Do you have a favorite scientist? If so what did they create or discover?*

Parent Section

Please have a parent or guardian complete this section

Parent / Guardian Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Cell Phone*

Emergency Contact

Please indicate a person we should contact in an emergency situation if the parent/guardian is not available.

First Last

Emergency Contact Phone #

Is your child able to attend the full 6 week program from July 5th - August 12th?*

Yes
No

Is you child able to attend program classes on Monday through Thursday from 9:00am-3:00pm, with a 45 minute lunch break?*

Yes
No

What is your child's date of birth?*

What is your child's gender?*

Male
Female
Non-Binary / Gender Fluid
Other

What is your child's race/ethnicity?*

Black / African American
Hispanic / Latinx
Multi Racial
Asian
Native Hawaiian or Pacific Highlander
American Indian/Alaskan Native
White

What grade will your child enter in Fall 2022?*

7th grade
8th grade
9th grade

Does you child have any allergies (Food, bees, etc.)?

No
Yes

Please specify ...

COVID-19 Vaccination Status

Participants need to be vaccinated to ride the bus on field trips. If you child is not vaccinated, they can attend the program except on field trip days. Is your child vaccinated ?

Yes
No

Vaccination Card

Please upload a picture of your vaccination card.

Accepted file types: pdf, jpg, jpeg, gif, png, tif, tiff, Max. file size: 50 MB.

Please select the size of your household

Please select your annual household income range.*

Photo and video release*

I agree to have my child participate in STEM activity photos or videos. I understand that these photos/videos may be used for Millhill newsletters, publications, media publicity, including social media.
I do not give permission to have my child participate in STEM activity photos or videos.

Transportation Waiver*

I hereby give permission for my child to attend enrichment activities during the STEM Explorers Program by being transported by bus. I hereby release Millhill Child and Family Development as well as all affiliated directors, officers, employees, and agents, from any and all claims, demands, causes of action, and liabilities in the case of an injury to my child while he/she/they is on any trip. If you do not wish to have your child ride the bus, it will be your responsibility to transport your child to and from all activities. By my signature, I affirm that I have read and understand this waiver.

Yes, I give permission for my child to ride the bus.
No, I do not give permission for my child to ride the bus.

Transportation Waiver

Parent/Guardian Consent
By signing below, I give consent for my child to participate in the Millhill STEM Summer Explorers Program and will support their attendance and participation.

Please sign below*

Use your cursor/mouse or finger (if you're on a phone or tablet) to sign in the space provided above.

Comments

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