2022-23 DMV NSBE, Jr. Membership Application & Registration2
DMV NSBE, Jr a volunteer led, Pre-College Initiative (PCI) NSBE, Jr. chapter is a year-round program (October 8th - June 3rd) hosted by the Dynamic Mathematical Visionaries Chapter of the National Society of Black Engineers.

NSBE, Jr.’s PCI is targeted towards 3rd –12th grade underrepresented students to provide encouragement, support, and assistance in their pursuit of a college education.  Our chapter also offers non-competitive programming for students in grades K-2 which will prepare them to become full NSBE, Jr. members once they reach 3rd Grade.  

The program’s aim is to increase the number of underrepresented students who are prepared to enter college; moreover, qualified to pursue majors in engineering, math, science, and other technical & STEM disciplines.

WHY JOIN DMV­ NSBE, JR.?

● Exposure to collegiate life through mentors, college tours & workshops
● Hands-on STEAM activities and field lessons
● In-depth look at STEM (Science, Technology, Engineering, and Mathematics) curriculum,
       and career opportunities
● Build leadership skills & gain professional experience
● Attend NSBE conferences, network with current and future engineers and other STEM  
        professionals

WHO IS ELIGIBLE?
DMV ­NSBE, Jr. is designed for students typically underrepresented in STEM  who will be in grades K-2 (Non-Competition) & 3rd–12th (Competition Based) and live in the DC Metro Area.  *Any student (regardless of physical location) can join our chapter and participate in any virtual and/or in-person activities as long as they can get to (and be actively engaged in) the activities.

WHAT DOES THE DMV ­NSBE, JR. PROGRAM INCLUDE?
The program consists of several events, the majority scheduled on weekends, over the upcoming school year virtually and at Mary McLeod Bethune Public Charter School once we return to in-person activities. The events include a variety of competition practices, STEAM activities, field trips, workshops, and seminars.  Most of the costs for activities, workshops & field trips are included in the chapter dues, with some activities having additional minimal fees associated.  **Students in Grades K-5 may choose & participate in one robotics-type "competition program" (if available during the season) while also participating in KidWind AND all other age/grade appropriate enrichment class offerings.  Students in Grades 6-12 may choose & participate in one "math competition" (MathCounts, MathCounts Video Challenge or TMAL) AND one "technical competition" (FLL, VEX IQ, Future City, KidWind, NSBE Technical Science Fair or VEX), based program while also participating in all other age/grade appropriate enrichment class offerings. **Participation in more than one competition-based program is totally optional AND based on your child's ability to participate at 85-90% for each activity chosen.

Chapter meetings will tentatively take place on the the 1st Sunday of the Month from 5-6pm VIRTUALLY unless otherwise stated throughout the 2022-23 program year.  All DMV-NSBE, Jr. students AND their parents/guardians are expected to attend & participate in ALL meetings and events. Tentative dates for the DMV ­NSBE, Jr.­ workshops, field trips & special events will be listed on our new chapter Google calendar.  **Please be sure to subscribe once you receive the email invite!  **Unless specified by one of the chapter advisors, DMV NSBE, Jr. chapter meetings & activities are "parent engaged & involved" and NOT "drop-off" events.  Parents, guardians (or a responsible adult family member ex: God-parent, Aunt, Uncle, Grandparent, etc) can and should volunteer & be engaged on your behalf when you are not available - however, please understand that our chapter's effective success depends on a "co-op" & FUBU (For Us By US) mantra with parents serving as co-coaches & team parents of teams; on chapter committees; as well as in other areas as needed by the organization.  

**Before completing this application for membership, each child must 1st join the National NSBE organization at www.nsbe.org (Cost: $5) and designate DMV NSBE, Jr. (in Region 2) as your NSBE, Jr. chapter.  **The membership MUST be in the student's name NOT the parent's name.  Also be sure to use a valid email for the student membership (5th-12th Grade members should use their own email).    

WHAT IS IN A COMPLETE DMV NSBE, Jr. APPLICATION PACKET?
A.    National NSBE Membership ($5)
B.    PCI Application Form
C. Parent Permission Form
D. Health Treatment Authorization, Medical Forms & Media Release
E. Completed Student Questionnaire
F. Paid 2022-23 Chapter Dues $350 (per new student) $300 (per returning student) (Before October 14th) & $400 (per new student); $350 (per returning student (after October 15th)

**Team & class registrations WILL NOT be finalized until application & chapter dues (In Full) are received.  A minimum of eight (8) students are required in order for a program to be considered "viable."  Additionally, two (2) parents are needed to co-coach  each team.   Space is limited for each program (robotics, math & other technical competitions) & enrichment class.  

Please complete & submit all forms electronically via Google Forms.  Chapter dues can be paid on our website via PayPal (additional 2.9% fee) or sent in the mail via Money Order or Check to: DMV NSBE, Jr. ~ 3401 12th Street, NE ~ Suite #4520 ~ Washington, DC  20017  

*Participants will be notified of membership via email within 10 days.
*Please note that Incomplete Applications will not be considered.
*Membership Deadline October 30th (After this date, NO new members will be accepted)




This 1st question is for the Parent.
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Email *
Family Info
Please tell us more about your DMV NSBE, Jr Scholars
Student #1 Full Name *
Student #1 NSBE Membership # *
Gender *
Date of Birth & Current Age (include both) *
Full Name of School (Is it Public, Public Charter, Private or Home school?) *
Grade this member will be in as of Fall 2022; AND their Current GPA (Students in Grades 3-12) **Students in grades 3-12 (with a GPA of 3.2 or above) are eligible for NSBE APeX Status.  All members, must email us a PDF copy of your most recent Report Card or transcript by Fri, October 28th (June 2022 Report Card is acceptable if current marking period has not yet ended) *
Student Email Address (MS & HS Students Only)*All students will be included on the Google Calendar & other important chapter emails.  
Student Cell Phone Number (MS & HS Students Only)
What is Your Current Math Class? (MS & HS Students Only) *K-5th Graders answer N/A.
What is your most recent PSAT or SAT Score. (HS Students Only) *K-8th Graders answer N/A.
List 3 Colleges/Universities of Interest? (Students in Grades 6-12)
List College Major(s) of Interest? (Students in Grades 6-12)
Technical PCI Robotics Program (Choose Only One) *
Technical PCI Program (Choose Only One) *
Math PCI Program (Choose Only One) *
Student #1 Enrichment Classes (*Space is limited; 1st 25 Members w/Paid Dues) *
Required
Does Student #1 have any food allergies, aversions or dietary restrictions?  Do they take ANY medication or have medical concerns of which the coaches should be made aware? *
Sibling #2 Full Name
Sibling #2 NSBE Membership # *
Sibling #2 Gender
Clear selection
Sibling #2 Date of Birth & Current Age
Sibling #2 Name of School (Is it Public, Public Charter, Private or Home school?) *
Sibling #2: Grade this member will be in as of Fall 2021; AND their Current GPA (Students in Grades 3-12) **Students in grades 3-12 (with a GPA of 3.2 or above) are eligible for NSBE APeX Status.  All members, must email us a PDF copy of your most recent Report Card or transcript by Fri, October 25th (June 2021 Report Card is acceptable if current marking period has not yet ended) *
Sibling #2: Email Address (MS & HS Students Only) *All students will be included on the Google Calendar & other important chapter emails.   *
Sibling #2: Cell Phone Number (MS & HS Students Only)
Sibling #2: What is Your Current Math Class? (MS & HS Students Only) *K-5th Graders answer N/A. *
Sibling #2: What is your most recent PSAT or SAT Score. (HS Students Only) *K-8th Graders answer N/A. *
Student #2: Shirt Size (New Members ONLY)
Sibling #2: List 3 Colleges/Universities of Interest (Students in Grades 6-12)
Sibling #2: List College Majors of Interest? (Students in Grades 6-12)
Sibling #2: Technical PCI Robotics Program (Choose Only One)
Clear selection
Sibling #2: Technical PCI Program (Choose Only One)
Clear selection
Sibling #2: Math PCI Program (Choose Only One)
Clear selection
Sibling #2 Enrichment Classes (*Space is limited; 1st 25 Members w/Paid Dues)
Does Sibling #2 have any food allergies, aversions or dietary restrictions?  Do they take ANY medication or have medical concerns of which the coaches should be made aware?
Sibling #3: Full Name
Sibling #3 NSBE Membership # *
Sibling #3: Gender
Clear selection
Sibling #3: Date of Birth & Current Age
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DD
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YYYY
Sibling #3: Name of School (Is it Public, Public Charter, Private or Home school?)
Sibling #3: Grade this member will be in as of Fall 2021; AND their Current GPA (Students in Grades 3-12) **Students in grades 3-12 (with a GPA of 3.2 or above) are eligible for NSBE APeX Status.  All members, must email us a PDF copy of your most recent Report Card or transcript by Fri, October 25th (June 2021 Report Card is acceptable if current marking period has not yet ended)
Sibling #3: Email Address (MS & HS Students Only)
Sibling #3: Cell Phone Number (MS & HS Students Only)
Sibling #3: What is Your Current Math Class? (MS & HS Students Only) *K-5th Graders answer N/A. *
Sibling #3: What is your most recent PSAT or SAT Score. (HS Students Only) *K-8th Graders answer N/A. *
Student #3: Shirt Size
Sibling #3: List 3 Colleges/Universities of Interest (Students in Grades 6-12)
Sibling #3: List College Majors of Interest? (Students in Grades 6-12)
Sibling #3: Technical PCI Robotics Program (Choose Only One)
Clear selection
Sibling #3: Technical PCI Program (Choose Only One)
Clear selection
Sibling #3: Math PCI Program (Choose Only One)
Clear selection
Sibling #3 Enrichment Classes (Incl, in chapter dues unless otherwise stated "Additional Nominal Fee)
Does Sibling #3 have any food allergies, aversions or dietary restrictions?  Do they take ANY medication or have medical concerns of which the coaches should be made aware?
Parent/Guardian Names (Both, if applicable) *
Parent/Guardian Cell Phone Numbers & Email Addresses (Both, if applicable) *
Home Address *
Name & Contact Number of Emergency Contact #1 *
Name & Contact Number of Emergency Contact #2 *
DMV NSBE, Jr is a volunteer-led organization.  Many hands make for light work!  Team coaches are needed for the continued success of our chapter.  In order to have a team, 2 Parent Coaches & at least 2 Team Parents are needed.  **No experience is required & training will be provided.  Would you be interested in serving as a parent co-coach or team parent of one of your child's teams?  Yes, (name the program: FLL, VEX IQ, KidWind, etc)  No, I will not be able to coach a team, but I will volunteer on a chapter committee or in another capacity (name what you will do to be actively involved) as needed by the organization.  I fully understand that this is a volunteer-led organization and the success of DMV NSBE, Jr is dependent upon actively engaged & involved parents like me.  I further understand that parent participation is expected and that membership for my student(s) in DMV NSBE, Jr means that I will serve where needed & contribute to the organization's success. *
Legal Liability Release *Please read the following waivers & agreements carefully. They include release of liability and waiver of legal rights, and deprive you of the ability to sue DMV NSBE, Jr. or its' Advisors. By agreeing electronically, you acknowledge that you have both read and understood all text presented to you as part of the registration process. **You will also receive a copy via email after our 1st chapter meeting (Nov 1st)  for your records. *
Competition Attendance Policy: All DMV NSBE, Jr. members are required to meet an 85% attendance requirement in order to participate in competitions. Competitive Team members are selected by coaches & approved by the Chapter Advisors based upon their attendance, academic grades and decorum based on NSBE's Code of Conduct.  As competitions near, additional team practice hours will be required.  **Parents/guardians must contact their coaches AND email the Lead Program Advisor (within 24 hrs) if their child will be absent from weekly practice.  Each team depends on the attendance of every member - continued absences prevent the growth of camaraderie & technical progress among the team.  Additionally, consistent absences (incl. late arrival & early dismissal) may result in non-participation in regional and national competitions of the member.   Weekly attendance will be tracked by coaches & event facilitators. *Unless otherwise stated, competitions will be virtual - however there may be in-person competitions with limited team member invitation. *
DMV NSBE, Jr. Academic Policy: Our members' academic success in school is paramount & comes before any and all DMV NSBE, Jr. activities & competitions.  Knowing that our members are capable of excellence, all members are required to maintain a B average (or higher) during each grading period.  In accordance with NSBE National Guidelines for GPA Verification (which also determines APeX Status), all students must provide current report cards; progress reports or transcripts at the end of each marking period.   *Every DMV NSBE, Jr member has an IXL subscription to help maintain their academic progress & acceleration.  On average, students should complete 30 min per weekday in Math (1hr daily on weekends).  Students have access to Math & Language Arts.  We will make every attempt to provide additional academic support to students falling below this academic expectation. *
Medical Release: Each DMV NSBE, Jr. member must be covered by their own medical insurance policy.  I hereby consent & authorize the Advisors and Coaches of DMV NSBE, Jr. to act in their best judgement with regards to my child in any emergency situation.  I further understand that any medical expenses will be billed directly to the insurance company of the parent/guardian.  I hereby waive & release DMV NSBE, Jr. from any and all liability for injuries or illnesses incurred while participating in any DMV NSBE, Jr. activities. *
DMV NSBE, Jr. Code of Conduct Policy:   DMV NSBE, Jr. members (and parents) will follow NSBE's National Code of Conduct as well as that of Mary McLeod Bethune PCS and any University we collaborate with and/or visit. As there may be times where we will be on different University campuses, we must always understand that the Universities are places of learning by adult, college-aged students - it is our duty as parents to maintain an environment that is conducive for the university students to study and safe for our under-aged chapter members.  Parents of DMV NSBE, Jr. members will ensure that their children (and children under their charge) adhere to this policy or face losing membership in the chapter.  **A detailed copy of both the NSBE Code of Conduct and our partner schools/University's Codes of Conduct will be included in the 2021-22 Chapter Handbook, available for download on the DMV NSBE, Jr. website. *
Media Release: I, the parent/legal guardian of the DMV NSBE, Jr. member or members, do hereby grant DMV NSBE, Jr. (and its partner or affiliated organizations that work with DMV NSBE, Jr. to provide the STEM services) a royalty-free, perpetual, irrevocable, worldwide license to use, distribute, reproduce, copy, publish, publicly broadcast broadcast, transmit, modify, print, create derivative works of and otherwise use the images of my child(ren) or myself, as specified in this Media Release. This includes the use of photographs, images, and/or video taken of my child(ren) or myself in any and all media now or hereafter known, for use in materials that include, but is not limited to, any printed or video marketing, promotional or educational materials and/or digital images on the DMV NSBE, Jr. website or that of our partner or affiliated organizations.  I understand that the partner or affiliated organizations working with DMV NSBE, Jr. may also require an additional release to supplement the release herein.You represent and warrant that you have all the rights necessary to grant the rights in this release, that you have obtained all necessary permissions or releases from third parties to grant such rights (including permissions from parents or guardians on behalf of minors).I represent that I am at least eighteen years of age, am competent and have authority to execute this release. *
Virtual Participation: During the pandemic, I understand that the majority of our programming may be virtual (using Zoom or Microsoft Teams).  To support our dedicated program facilitators & coaches, I will ensure that my scholars have their cameras on and visually and actively participate in all activities and sessions. *
DMV NSBE, Jr's Parent Village Commitment:  DMV NSBE, Jr. has won Region 2 NSBE, Jr Chapter of the Year from 2018-2021!  Three years in a row!  Many hands make for light work & it takes a village of dedicated parents to change the face of STEM for our children.  Acknowledging that this is a volunteer-led organization, with a high level of parent involvement, I agree to be an active & engaged part of the DMV NSBE, Jr. Village by: *
Chapter Dues Payment:  Parents should make payments via PayPal using the link at the bottom of the Join NSBE or Membership pages of our website or by sending a Money Order or Check to: DMV NSBE, Jr.'s Mailing Address on or before October 10th (To Avoid Increased Dues - October 30th is the FINAL Registration Deadline).  Completion of this application without payment of Chapter Dues does not guarantee registration for a team, nor participation in an enrichment activity/class.  **2021 Chapter Dues DO NOT include registration for the 48th NSBE Convention (in Anaheim, CA). Please note, if attending, registration, transportation and lodging will be additional fees. *
Electronic Signature of Parent/Guardian *
Electronic Signature of the Student Member *
Student Member: To complete this application, search the internet and copy/paste the entire NSBE Mission below.  Now, read the Mission out loud to your parent(s).  K-1st grade members, have your parent(s) read the Mission to/with you.  **All NSBE, Jr Members AND parents are expected to memorize the Mission by October 29th.  Welcome to the DMV NSBE, Jr Family! *
Dynamic Mathematical Visionaries (DMV) NSBE, Jr.
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