College Impact Alpha Summer Application and Release 2021

College Impact Alpha Summer Application and Release 2021

The College Impact Alpha program will take place on Florida International University's Biscayne Bay Campus. Buses to and from participating high schools will be provided: Miami Jackson Senior High School, Miami Springs Senior High School, Hialeah Senior High School, American Senior High School, North Miami Beach Senior High School, Norland Senior High school, Miami Central Senior High School, William H. Turner Technical Arts High School
Camp Hours: 9:30 AM - 3:30PM
Camp Dates: June 14 - July 30

Name Name First Last
Sex

Sex Male Female Non Binary Other Other
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Birthdate Birthdate / MM / DD YYYY
Phone Phone - ### - ### ####
Email
MDCPS Email
Ethnic Background

Ethnic Background Black/African American Hispanic/Latino White Asian Pacific Islander American Indian Other Other
School
Student ID Number
Grade Level
Please enter your current or final Maths grade
Please enter your current or final English grade
Please enter your current or final Science grade
Have you participated in After School All Stars before?
If yes, to the last question, please list the name of the site.

Choose your preferred main program of study for this summer. 1 = highest and 4 = lowest
	1	2	3	4
Robotics and Coding	Robotics and Coding1	Robotics and Coding2	Robotics and Coding3	Robotics and Coding4
Healthcare Explorer	Healthcare Explorer1	Healthcare Explorer2	Healthcare Explorer3	Healthcare Explorer4
Engineering	Engineering1	Engineering2	Engineering3	Engineering4
Science	Science1	Science2	Science3	Science4

Emergency Contact

Please list emergency contact information below
Emergency Contact One Emergency Contact One First Last
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Emergency Contact Two Emergency Contact Two First Last
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
In the event no one can be contacted, I give consent for my child to receive emergency medical treatment

In the event no one can be contacted, I give consent for my child to receive emergency medical treatment yes no
Please provide any other important information regarding your child.
Draw your signature into the box below.

Draw or Type

I certify that the information given here is true and correct. I give my consent for my child to attend field trips, cultural events and workshops. I relieve the College Impact Program at Florida International University and South Florida After-School All- Stars of any responsibility for accidents, illnesses, or injuries including death that may result from participation. I release the released parties from all claims, damages, actions, or causes of actions which may occur due to any decisions made with respect to the medical care or treatment of my child. I authorize the use of my child’s in interviews, the use of quotes, and the taken of photographs, movies or video tapes in program publications, newsletters, and websites. I authorize counselors or schools to release my child’s transcript information regarding educational progress, any financial aid award, and enrollment status to the College Impact Program.

I understand this is a legal representation of my signature. Clear

Full Name

I certify that the information given here is true and correct. I give my consent for my child to attend field trips, cultural events and workshops. I relieve the College Impact Program at Florida International University and South Florida After-School All- Stars of any responsibility for accidents, illnesses, or injuries including death that may result from participation. I release the released parties from all claims, damages, actions, or causes of actions which may occur due to any decisions made with respect to the medical care or treatment of my child. I authorize the use of my child’s in interviews, the use of quotes, and the taken of photographs, movies or video tapes in program publications, newsletters, and websites. I authorize counselors or schools to release my child’s transcript information regarding educational progress, any financial aid award, and enrollment status to the College Impact Program.

I understand this is a legal representation of my signature.