Student Enrollment Form
Personal Information
First Name
*
Last Name
*
Date of birth
*
Contact Information
Address
*
City
*
State
*
Zip code
*
Phone
*
Email
*
What type of STEM training are you looking for?
Drone Training
3D Printing
Solar Energy
Hydroponics
Digital Marketing
Race/Ethnicity: (Please select all that apply)
Race
*
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian Pacific Islander
White
Multi-Racial
Other
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Gender
*
Male
Female
Other
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Household Information
Marital Status
*
Single
Married
Separated
Divocred
Widowed
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Annual Household Income $
*
How many people live in your household?
*
Employment Status
*
Unemployed
Full-time
Part-time
On-call
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I understand that all information provided is true to the best of my knowledge. I understand they any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability. By signing this form, I authorize Nevada Partners, Inc. to provide transportation for my child to attend STEM Center programs and release NPI from liability.
I understand and agree
*
I understand and agree
Today's Date
Parent Signature and Agreement
*
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