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Summer STEM Workshops Registration Form
WEST ANGELES EDUCATION & ENRICHMENT PROGRAM
Student First Name
*
Student Last Name
*
School Name
*
Age
*
Fall 2021 Grade
*
Sex
*
Female
Male
Ethnicity
*
African American
Latino
White
Asian
Other
Student Email
West Angeles Member?
*
Yes
No
Does your student have any special learning needs?
*
Yes
No
Full Name (GUARDIAN # 1)
*
List first and last name
Relationship to Child
*
Father
Mother
Grandparent
Other Relative
Family Friend
Legal Custodian
Email Address
*
Cell Number
*
Home Number
Street Address
*
City
*
Zip Code
*
Full Name (GUARDIAN # 2)
*
If I am unavailable, please contact this guardian in case of an emergency or urgent request.
Phone Number (GUARDIAN # 2)
*
Relationship to Student (GUARDIAN # 2)
*
Father
Mother
Grandparent
Other Relative
Family Friend
Legal Custodian
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