Urban League of Nebraska
Whitney Young Jr.
Girl’s STEAM Academy
Student Information PLEASE PRINT (ALL INFORMATION MUST BE FILLED IN)
Girl’s Name ______Grade______Birthdate______School______
Address_______City______State______Zip______
Home (______)______Cell (______) ______Work (______) ______
Email______Facebook Name ______Instagram Name ______
Racial background (please check as many as apply) ______American Indian or Alaskan Native______Asian ______Black or African American
______Hawaiian or Pacific Islander ______White______Other (please specify) ______
The STEAM Academy program will include the opportunity to shadow a professional in the career field of your choice. Please include your top three desired career fields. This will allow us to arrange shadow opportunities with as many professionals as needed. (Choose Three)
Business/Finance
Ex. Accountant, Banker, or Marketer
Medical/Health
Ex. Nurse, Doctor, or Pharmacist
Law/Criminal Justice
Ex. Lawyer, Judge, or Police Officer
Education
Ex. Teacher or Principal
Technology
Ex. Programmer, Designer, or Developer
Arts/Entertainment
Ex. Singing, Acting, Dancing, or Painting
Engineering
Ex. Civil or Architectural
Other (please specify)
Guardian Information
Name ______Relation to student______
Address______
Street______City______State ______Zip______
Home (______) ______Work (______) ______Cell (______) ______
Email______
Does your child receive free or reduce lunch? Y or NWillyour child be the first to go to college in your family? Y or N
Is your child in foster care? Y or NDo you receive government assistance? Y or N
Annual Income
Under $10K $10K-19,999 $20K-29,999 $30K-39,999 $40K-49,999 $50K-59,999 $60K and over Unknown
Emergency Contact
In case of an EMERGENCY, we should contact the following person(s) if parents cannot be reached. (Please list names in order you would like them to be called.)
Name ______Phone ______Email______Relationship ______
Name ______Phone ______Email______Relationship______
General Health Questions
Allergies (if any)______
Medication (if any)______Possible side effects______
Family Doctor______Phone______
Any activities child should NOT engage in______
My daughter has my permission to attend the Urban Leagueof Nebraska’s Whitney Young Jr.Girl’s STEAM Academy! We understand that when participating in Urban League activities the registrant may be photographed for print, video, or electronic imaging. We understand that the images may be used in promotional materials, news releases and other published formats. We acknowledge that the images will be the sole property of Urban League of Nebraska.
______
Parent/Guardian SignatureDate
Urban League of Nebraska
Whitney Young Jr.
Girl’s STEAM Academy
LIABILITY WAIVER FORM
As parent or legal guardian of
______
I gives consent for the above named student to participate in all of the Urban League of Nebraska’s sponsored activities, including all field trips which includes both walking and vehicle transportation.
In the event that medical treatment is required, and neither guardian nor emergency contact can be reach, I give authorization to the staff to obtain necessary and adequate medical treatment for my child. If any medical fees are involvedI will take sole responsibility of any financial matters which the Urban League of Nebraska will not be responsiblefor.
I hereby release and hold harmless Urban League of Nebraska, its employees and agents from actions arising from the Whitney Young Jr. Girls STEAMAcademy.
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Signature of Parent or Legal GuardianDate
______
Parent Name (Print or Type)
T-Shirt Order Form
Name: ______
Please circle the T-Shirt size