Spring 2021 STEM Scholars Registration Form
This form is to collect necessary information from students enrolling in the STEM Scholars program through the University of Illinois-Chicago.
For more information about the program please visit: https://stemscholars-erc.uic.edu/
or email the Program Manager Caroline Hernandez at cah272@uic.edu
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Email *
First Name *
Last Name *
Street Address *
City *
Zip Code *
Which of the following best represents your racial or ethnic heritage? Choose all that apply. *
Required
What is your gender? *
Cell Phone Number  (ex. (xxx) xxx-xxxx) *
Home Phone Number (ex. (xxx) xxx-xxxx) *
Name of High School   *
Grade Level *
Birthday *
MM
/
DD
/
YYYY
Parent or Guardian's name *
Parent or Guardian's cell phone (ex. (xxx) xxx-xxxx) *
Parent or Guardian's work phone  (ex. (xxx) xxx-xxxx) *
How did you find out about this program? *
Have you participated in other after school programs before? *
Required
What are you plans after graduating high school? *
What careers are you considering at this time? *
Have you considered or were you ever considering college after high school? *
What are your favorite subjects in school? *
What do you enjoy learning about the most? *
What do you enjoy learning about the least? *
What are some things that might prevent you from doing well in your classes? (Choose all applicable options) *
Required
Do you have internet access at home or easy access to internet daily? If not, please explain and we will do our best to support you. *
Required
Do you have access to a computer at home daily? If not, please explain and we will do our best to support you. *
We understand that Covid-19 has had significant impacts on families across the U.S., are there any aspects your family is struggling with that we could potentially help you with? If so, what? *
What days are you available to attend one session a week from 3:00- 5:00pm for six weeks? Please select all that you are available. *
Required
If you cannot make any of these calls, what time and day work best for you? (Only Monday through Friday
Are there any topics you are particularly interested in learning/experiencing in this after school program? *
I hereby grant permission to the Energy Resources Center at the University of Illinois Chicago, to take and use: photographs and/or digital images of me for use in news releases and/or educational materials. These materials might include printed or electronic publications, Web sites or other electronic communications. I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the image(s).   *
Required
Name for consent.
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