SECTION I. CONTACT INFORMATION
Prefix: Mr. Ms.
First Name: Middle Initial
Last Name: Suffix
School Name:
Grade Level : (in Fall 2017)
Home Address:
City: State:
Country: Zip
Home Phone: ( ) -
Mobile Phone: ( ) -
Email::
School Address:
City: State:
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. 

SECTION II. PERSONAL PROFILE
1.Gender: Male Female 2.  Date of Birth: mm/dd/yyyy
3. What is your ethnic background?

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: