Name *

First Name

Last Name

Cell/Home Phone *

(###)

###

####

I AM INTERESTED IN VOLUNTEERING ?

Yes

No

Are you over 18 yrs of age ?

Yes

No

I AM INTERESTED IN THE FOLLOWING PROGRAMS FOR MY CHILD(REN) (CHECK ALL THAT APPLY):

STEMgirls Weekly Workshops, multiple locations

Coding & Gaming Club for Elementary & Middle School Students, multiple locations

STEAMcamp Summer School at Joseph Caruso School, Keansburg, July 2020

Inspire LIFE! Fine Arts & Technology Camp at Second Baptist Church, Asbury Park, August 2020

Other

Child1: Name

First Name

Last Name

Child1 : Birthdate

MM

DD

YYYY

Child 1: Gender

Female

Male

Child 2: Name

First Name

Last Name

Child 2: Birthdate

MM

DD

YYYY

Child 2: Gender

Female

Male