2024 STEM YEA STUDENT REGISTRATION FORM
Enter information about the student registering for the 2024 STEM YEA Academy to be held Thursday, July 11th through Sunday, July 14th, 2024 at Kutztown University, Kutztown, PA.  Please enter your email address, your name and relationship to the student applicant in the first 3 fields.  The remaining fields relate to the student applicant.
Once you have completed all the information, press the SUBMIT button to record your entry. (No data is saved unless you press the SUBMIT button).  An email will be sent to you confirming the information you entered.  The email you receive will contain an EDIT RESPONSE button which will allow you to re-access the form, if needed,  to modify information previously entered.  If modifying information, please remember to press the SUBMIT button to save your modifications. (Please save these email responses to you as they verify information entered and allow you to modify the record if needed)

After completing this form please download the Waiver, Permissions, and Agreement  document. 
It needs to be reviewed, signed, and the signature (last) page emailed to registration@stemyea.com
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Email *
Your Name (First and Last) *
As the person entering data into this form, please enter your name
Your Relationship to the Student Applicant *
Please enter your relationship to the student applicant  (mother, father, teacher, advisor, etc.)
Student's First Name *
Student's Last Name *
Birth Date *
MM
/
DD
/
YYYY
Gender *
Is the student Hispanic or Latino? *
Race (check as many as apply) *
Required
Student's Email Address *
If the student doesn't have an email address, enter NONE
Address Street Number and Name *
City *
State *
Zip Code *
Student Tee Shirt Size (select one) *
Will the student have a Smart Phone during the Academy? *
Student's Phone Number *
If student doesn't have a phone number, enter NONE
Does student have computer access at home? *
Please list any dietary restrictions of student *
If there are no dietary restrictions, enter NONE
Other special needs? *
If there are no other special needs, enter NONE
Parent/Guardian Name (First and Last) *
Parent/Guardian Email Address *
If parent/guardian does not have an email address, enter NONE
Parent/Guardian Phone Number *
Backup Emergency Contact Name (First and Last) *
This should be a different person than the Parent/Guardian named above
Backup Emergency Contact Phone Number *
School that the Student Attends *
Current Grade Level of the Student *
Name of the sponsoring Rotary Club *
Commitment by the student to attend a meeting of the sponsoring Rotary Club to share their experience at STEM YEA following the STEM YEA Academy *
Commitment signature that the student and parent/guardian understand and acknowledge the student must attend the full 4-day, 3-night program. *
Commitment that the parent/guardian or sponsoring Rotary Club must provide transportation to Kutztown University between 12:00PM and 1:00PM on Thursday, July 11, 2024 and from Kutztown University on the evening of Sunday, July 14, 2024. *
School District Administrators, middle school Principals, school counselors or Local Rotary Club reps work with the parents to complete the required documentation.  The documentation includes: 
1.  On-line Registration form (this form should be completed);
2.  Waivers, Permissions and Agreements document.  Please read and sign last page. You can download this form using this link:                                         https://stemyea.com/forms/STEMYEA-Waivers-Permissions-Agreements.pdf
3.  Physical Examination Form (6th grade Health History Form) signed by the student’s doctor
4.  COVID Vaccination History Card  (COVID vaccination is recommended but not required)

The Physical Examination Form (6th grade Health History form) and COVID Vaccination History Card should be scanned and emailed to registration@stemyea.com
 
Only the LAST signed page of the Waivers, Permissions and Agreements document should be scanned and emailed to registration@stemyea.com  
A copy of your responses will be emailed to the address you provided.
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