Code Ninas Registration

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: *

date of birth *

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 *

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: *

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 *

I agree to receiving marketing and promotional materials

Submit