SECTION I. CONTACT INFORMATION
Prefix:
Mr.
Ms.
First Name:
Middle Initial
Last Name:
Suffix
Jr.
Sr.
II
III
IV
School Name:
Grade Level :
(in Fall 2017)
Home Address:
City:
State:
Alabama(AL)
Alaska(AK)
American Samoa(AS)
Arizona(AZ)
Arkansas(AR)
California(CA)
Colorado(CO)
Connecticut(CT)
Delaware(DE)
District of Columbia(DC)
Florida(FL)
Georgia(GA)
Guam(GU)
Hawaii(HI)
Idaho(ID)
Illinois(IL)
Indiana(IN)
Iowa(IA)
Kansas(KS)
Kentucky(KY)
Louisiana(LA)
Maine(ME)
Marshall Islands(MH)
Maryland(MD)
Massachusetts(MA)
Michigan(MI)
Minnesota(MN)
Mississippi(MS)
Missouri(MO)
Montana(MT)
Nebraska(NE)
Nevada(NV)
New Hampshire(NH)
New Jersey(NJ)
New Mexico(NM)
New York(NY)
North Carolina(NC)
North Dakota(ND)
Ohio(OH)
Oklahoma(OK)
Oregon(OR)
Palau(PW)
Pennsylvania(PA)
Puerto Rico(PR)
Rhode Island(RI)
South Carolina(SC)
South Dakota(SD)
Tennessee(TN)
Texas(TX)
Utah(UT)
Vermont(VT)
Virgin Islands(VI)
Virginia(VA)
Washington(WA)
West Virginia(WV)
Wisconsin(WI)
Wyoming(WY)
Country:
Zip
Home Phone:
(
)
-
Mobile Phone:
(
)
-
Email::
School Address:
City:
State:
Alabama(AL)
Alaska(AK)
American Samoa(AS)
Arizona(AZ)
Arkansas(AR)
California(CA)
Colorado(CO)
Connecticut(CT)
Delaware(DE)
District of Columbia(DC)
Florida(FL)
Georgia(GA)
Guam(GU)
Hawaii(HI)
Idaho(ID)
Illinois(IL)
Indiana(IN)
Iowa(IA)
Kansas(KS)
Kentucky(KY)
Louisiana(LA)
Maine(ME)
Marshall Islands(MH)
Maryland(MD)
Massachusetts(MA)
Michigan(MI)
Minnesota(MN)
Mississippi(MS)
Missouri(MO)
Montana(MT)
Nebraska(NE)
Nevada(NV)
New Hampshire(NH)
New Jersey(NJ)
New Mexico(NM)
New York(NY)
North Carolina(NC)
North Dakota(ND)
Ohio(OH)
Oklahoma(OK)
Oregon(OR)
Palau(PW)
Pennsylvania(PA)
Puerto Rico(PR)
Rhode Island(RI)
South Carolina(SC)
South Dakota(SD)
Tennessee(TN)
Texas(TX)
Utah(UT)
Vermont(VT)
Virgin Islands(VI)
Virginia(VA)
Washington(WA)
West Virginia(WV)
Wisconsin(WI)
Wyoming(WY)
Country:
Zip
Church:
Parent(s)/Guardian(s):
Mr.
Ms.
Mr.
Ms.
Mobile Phone:
(
)
-
Parent Email Address(es):
Email:
Email:
Mobile Phone:
(
)
-
Select the course or workshop you wish to enroll in.
Youth Coding Academy Teen Coder Boot Camp Fall 2017 T/R 6pm
SECTION II. PERSONAL PROFILE
1.Gender:
Male
Female
2. Date of Birth:
mm/dd/yyyy
3. What is your ethnic background?
African-American
Hispanic
Asian-American
Caucasian
Native American
Other (Please specify)
Other:
4. Does anyone in your immediate family code in any programming language(s)?
Yes
No If yes, which language(s)?
5. Do you have coding experience in the following? (Check all that apply)
C++
Java
Python
HTML
JavaScript
CSS
PHP
Ruby
SQL
Scratch
Alice
Do you own any computing devices?
Laptop
Tablet
Desktop PC
6. What do you hope to gain from the Teen Coder Boot Camp?
SECTION III. YOUR CODING PROJECT IDEA
1. Do you have a specific coding project in mind?
Yes
No
Project Description:
Recommended by: