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2021 Code Niñas Registration Form
For questions, please email Dr Rob at
rob@
ysa.world
Applicant Details
*
Indicates required field
Student Name
*
First
Last
I identify with gender:
*
Female
Genderqueer/Non-binary
I prefer not to say
date of birth
*
MM/DD/YYYY
School Name
*
Best Phone Number
*
Email
*
2021 School Year Grade Level
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
parent/legal guardian name
*
First
Last
Relationship to Applicant
*
-
Mother
Father
Legal Guardian
Program Requirements
Due to the generosity of the Jeff Gordon Chevrolet and nCino, the Code Niñas program is completely
free
. Throughout the semester, participants will receive a Code Niñas t-shirt and lanyard as well as other swag .
Please select your T-shirt size:
*
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Please provide brief (3-4 sentences) responses to the following questions:
Why do you want to participate in the Code Girls program?
*
How can we apply coding for good use in society?
*
Tell us something interesting about yourself
*
Why is diversity important in science?
*
Required
*
I agree
I agree and acknowledge that my child’s participation is not the responsibility of the Young Scientist Academy (YSA) or the Harrelson Center, its employees, officers, or agents. I affirm and agree that as parent/legal guardian, I will grant the approved supervisors, educators and chaperones from YSA the responsibility to supervise my child during YSA activities and field trips. I further agree and understand there are inherent risks attendant to these activities – including but not limited to personal injuries that may be sustained while participating in YSA activities. I expressly agree to assume any such risks on my behalf and that of my child. I also grant YSA permission to photograph and video my child, and publish these images on the YSA website and affiliated social media platforms.
signature of Parent/guardian
*
Relationship to student
*
date
*
MM/DD/YYYY
I agree to receiving marketing and promotional materials
Submit
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Earth Day Summit
About
Our Mission
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Contact
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