STEMNASIUM Application

STEMNASIUM LEARNING LAB

Acceptance into the STEMNASIUM SATURDAY'S program is for eligible ethnic minority students ages 11-14, who reside in the Summit Area YMCA service area of Berkeley Heights, Gillette, Millburn, New Providence, Short Hills, Springfield, Stirling and Summit and have a stressed financial need.
STUDENT INFORMATION
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

Other
School Name
Current Grade
Ethnic Origin
Please note: Y-USA requests the above information from YMCA participants throughout the nation for program funding and demographic purposes.
- PARENT/GUARDIAN INFORMATION
- Name
  
  First NameLast Name
- Relationship to Student
- Date of Birth
  
  MonthDayYear
- Phone Number
  Format: 000-000-0000.
- Email
  example@example.com
- EMERGENCY CONTACT INFORMATION
- Do you want to provide Emergency Contact information for the student that is different from the Parent/Guardian information provided above?
- Name
  
  First NameLast Name
- Relationship to Student
- Phone Number
  Format: 000-000-0000.
- Code of Conduct Agreement
- Waiver & Release of Liability
- Coronavirus/COVID-19 Warning & Disclaimer
- Please confirm you are not a robot
- Parent/Guardian Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Should be Empty:

STEMNASIUM LEARNING LAB