Urban League of Nebraska

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.

______

Signature of Parent or Legal GuardianDate

______

Parent Name (Print or Type)

T-Shirt Order Form

Name: ______

Please circle the T-Shirt size