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STEM Goes Red For Girls

November 2, 2018 - HIMSS Innovation Center
Global Center for Health Innovation, 1 St. Clair Ave, NE, Cleveland, OH 44144

Application Form

DEADLINE: October 12, 2018

Instructions:

Designate 8 students to attend the STEM Goes Red event on November 2nd - Student must identify as female in high school grades 7 through 9.
One (1) school-designated chaperone must accompany students through the duration of the program. (additional chaperones must be requested and approved by the American Heart Association)
Consent waivers are required for each student and must be submitted with this application. Download Consent Waivers HERE

School-Appointed Chaperone Contact Information:

Chaperone Name:*

Chaperone Title:*

Chaperone Phone:*

Chaperone Email:*

School:*

School Address:*

Student 1 Information (consent form/waiver required)

Student 1 Name:

Student 1 Grade:

7

8

9

Student 1 Special Accommodations (please check all that apply):

Vegetarian

Vegan

Kosher

Other (fill in details below)

Student 1 Other - Allergies or Special Needs:

Student 1 T-Shirt Size:

Small

Medium

Large

X-Large

Student 2 Information (consent form/waiver required)

Student 2 Name:

Student 2 Grade:

7

8

9

Student 2 Special Accommodations (please check all that apply):

Vegetarian

Vegan

Kosher

Other (fill in details below)

Student 2 Other - Allergies or Specials Needs:

Student 2 T-Shirt Size:

Small

Medium

Large

X-Large

Student 3 Information (consent form/waiver required)

Student 3 Name:

Student 3 Grade:

7

8

9

Student 3 Special Accommodations (please check all that apply):

Vegetarian

Vegan

Kosher

Other (fill in details below)

Student 3 Other - Allergies or Special Needs:

Student 3 T-Shirt Size:

Small

Medium

Large

X-Large

Student 4 Information (consent form/waiver required)

Student 4 Name:

Student 4 Grade:

7

8

9

Student 4 Special Accommodations (Please check all that apply):

Vegetarian

Vegan

Kosher

Other (fill in details below)

Student 4 Other - Allergies or Special Needs:

Student 4 T-Shirt Size:

Small

Medium

Large

X-Large

Student 5 Information (consent form/waiver required)

Student 5 Name:

Student 5 Grade:

7

8

9

Student 5 Special Accommodations (please check all that apply:):

Vegetarian

Vegan

Kosher

Other (fill in details below)

Student 5 Other - Allergies or Special Needs:

Student 5 T-Shirt Size:

Small

Medium

Large

X-Large

Contact Information

Company:

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country / Location:*

Mobile Phone:

Home Phone:

Email:*