Suriname Program Registration - STEM ACCESS FOR GIRLS

Parent / Guardian Name *

First

Last

Parent Email (If applicable) *

Parent Phone ( If applicable) *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Participant Name *

First

Last

Participant Date of Birth *

Gender

School/ Grade level

Participant phone # (If applicable)

Participant Email (If applicable)

Input email address to receive Zoom ID and password for each session.

T-shirt Size

Small
Medium
Large

You will need a cell phone or computer access to participate in the program. Do you have a working smartphone or computer access in your home or (i.e. that could access Whatsapp, Facebook or Zoom video conferencing)

Yes
No

What cell phone Carrier do you have?

Telesur
Digicel

What is the cell phone number that will be used for the STEM Access For Girls Program?

What languages do you speak at home?

Dutch
Sranang Tongo 
English

Would you like to be considered for a scholarship?

In 250 words or less, please describe your future goals or the child that will be participating in the program future goals in terms of education and career in science, technology, engineering and or mathematics ( STEM). If this will be your first STEM program, describe a problem you've solved or a problem you'd like to solve ?

what is your annual income for your household?

How many people are supported by those funds?

What else would you like to share that would help to illustrate your financial need?

How did you hear about our Youth Enrichment Development Program?