2021 FIRE UP! Application

EIS Logo
3-Week Summer
Coding & Robotics Program

Eligibility Requirements:
  • Female student entering 6th, 7th, or 8th grade in Fall 2021
  • Attend a Title 1 school in Fall 2021
Applying for this program does not guarantee student participation.

Camp Hours: 9:00am - 4:00pm
Program Fee: $25 application fee per student.
NO ADDITIONAL COST if the student is admitted into the program. Application fee will be refunded if the student is not admitted into the program.

Sessions Available (Choose one only)
Session 1: MON/June 21 - FRI/July 2 AND MON/August 23 - FRI/August 27
Session 2: MON/July 12 - FRI/July 23 AND MON/August 23 - FRI/August 27
Session 3: MON/July 26 - FRI/August 6 AND MON/August 23 - FRI/August 27
Session 4: MON/August 9 - FRI/August 20 AND MON/August 23 - FRI/August 27
Note: Admission limited to 12 students per session

There is a week of half-day virtual field trips held MON/August 23 - FRI/August 27. Students will be on virtual fieldtrips to local university or STEM business. *Subject to change due to the pandemic.
PARENT/GUARDIAN INFORMATION












This program is located in San Diego, CA ONLY
HOUSEHOLD INFORMATION


My household income is $
per year.
STUDENTS

STUDENT 1




MM/DD/YYYY




STUDENT 2




MM/DD/YYYY




 
AUTHORIZED ADULTS FOR PICK-UPS
Please provide the authorized adult(s) first name, last name, and phone number.






EMERGENCY CONTACTS






MEDICAL INFORMATION





TEMPORARY MEDICAL AUTHORIZATION
By enrolling my child(ren) to attend FIRE UP! 2021 at the Elementary Institute of Science (EIS), I, the parent/guardian, give EIS permission to act on my behalf in case of a medical emergency for my child(ren) while participating in the program.
 
PROGRAM APPLICATION FEE
$
This amount will be refunded if your student(s) is not admitted into the program.
IMPORTANT PROGRAM INFORMATION

Waiver of Liability
By submitting the registration for the student(s) above, the parent/guardian, listed on the form, hereby gives permission for said student(s) to participate in all the various activities, including field trips, of the Elementary Institute of Science (EIS). EIS does not assume financial or legal liability in case of injury or accident. The parent/guardian hereby waives all claims against the Elementary Institute of Science, its Board, employees, and volunteers for injury, accident, illness, or death that may  occur while participating in EIS programs.

Camp Participation
Applying for this program does not guarantee student participation. EIS will review all applications and determine which students will be admitted. Selection is NOT on a first-come-first-served basis. Parent/Guardian will be notified via email if their student(s) has been selected to participate in the program.

Participation Agreement
It is the aim of the Elementary Institute of Science (EIS) to create a fun and safe learning environment for both students and staff. In keeping with this goal, students are asked to be respectful to classmates and adults, respect EIS property and property of other students, enter and leave EIS in an orderly manner, and maintain a positive learning environment. Students who are unable to maintain a respectful learning environment may be dismissed from the program and considered ineligible for future scholarships.

Media Release
By allowing the student(s) to participate in this program, the parent/guardian agrees to authorize the Elementary Institute of Science (EIS) and various partner organizations to photograph, videotape, film, and/or quote the student. The parent/guardian authorizes EIS to permit the use and the publication of any photographs, videotape, or film of the student for publicity purposes, including release of such photographs, videotape, film, or quotes, to the news media and on the EIS website. It is agreed to hold harmless EIS, its officers, agents, and employees from any liability resulting from, or arising in connection with, the taking, publication, and release of the photographs, videotape, film, or quotes of the student in the agreement. Pictures and videos taken by EIS Staff will be shared with students, posted on Social Media, or in Print.
CREDIT/DEBIT CARD PAYMENT





Comments/Notes for EIS (Optional)


By submitting the application, the parent/guardian indicates that all of the above information is true and accurate to the best of your knowledge. The parent/guardian acknowledges that students will be selected by the Elementary Institute of Science to attend camp and will be notified of their status via email.


Please review your application before submitting.
(HIDDEN FIELDS)