STEM Coding Session

Jared's Heart of Success Inc.
Please provide information and once submitted and accepted you will recieve notification of location for this event
http://www.jaredsheartofsuccess.com

Participant Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Gender

Birth Date +

Grade

Race *

Black or African America

White

Latin/Spanish

Other

Elementary/Middle/High School *

Elementary School

Middle School

High School

Parent/Guardian Contact

Relationship to Participant: *

Self

Mother

Father

Guardian

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone

Alternate Phone

Emergency Contact Phone

Email Address *

In the event of an emergency and I can't be reached I give permission for my child/children to be treated by a physician and or hospital.

I give permission to photographs/video and other forms of media in which my child/children may appear during activities with JHOSI for its purpose.

I understand that I'm responsible for transporting my child/children to and from program activities, and at the start and conclusion of the program, I understand that my child/children may participate in a pre and post survey given during JHOSI programs. I do understand that information is gathered will be kept in confidence and used for evaluation purposes only.

Permission to attend Coding Session *

Yes

Signature *