The Genius Project Summer STEM Academy

The Genius Project is a three-week STEM concentrated summer Academy for African-American Kindergarten through 12^th grade students. Created in collaboration with Sacred Sistahs, Inc. and Immanuel Praise Fellowship, the program will provide an academic challenging, culturally enriching and gift affirming experience that pushes our children to genius.

Instruction will be provided by certified teachers, college students, field experts and volunteers. Each Friday, students will experience different STEM environments introducing them to the vast variety of careers in the STEM fields.

Monday, June 10, 2019 to Friday, June 28, 2019 Monday - Friday, 9:00 AM to 3:00 PM

Registration Deadline May 31st

Due to the program demand, waiting until the deadline to register may result in your child being placed on the waiting list.

Student (s) Information

Camp Fees: $150 per child/$75 per additional child in the family.

Full Name

Birth Date +

Grade

Gender

Fee ($)

Full Name

Birth Date +

Grade

Gender

Fee ($)

Full Name

Birth Date +

Grade

Gender

Fee ($)

Full Name

Birth Date +

Grade

Gender

Fee ($)

School district your student(s) attends?

Total Fees for all Participants:

0.00

Extended care hours before 8AM to 9AM after hours 3:30PM to 6:00PM *

I will not need extended care for my child(ren)

I will need extended care for my child(ren) $105 per child/$50 for each additional child in the family.

Enter Total Fees

If you need financial assistance please email simmons6197@gmail.com

Household / Adult Primary Contact

Relationship to Participants: *

Mother

Father

Guardian

Other Other

First Name *

Last Name *

Address 1 *

City *

State *

Zip *

Phone

Email Address *

Enrollment Packet

Emergency Contact Information– Alternate Pickup/Release

First Name *

Last Name *

Work Phone Number *

Cellphone Number *

Relationship to Child *

Medical Release Information

Physician Name *

Health Insurance *

Policy Number *

Phone Number

Preferred Hospital

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures). *

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? *

No

if Yes explain if Yes explain

Is your child allergic to any type of medication? *

No

if Yes explain if Yes explain

Meal and Snack Information

Is your child allergic to any type of food ? *

No

if Yes explain if Yes explain

Does your child require a special diet? *

No

if Yes explain if Yes explain

Liability Release and Parental Consent

Liability Release and Parental Consent Form *

I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to my child(ren) as a result of participation in said program. This release is intended to discharge in advance Immanuel Praise Fellowship, Sacred Sistahs, Inc each organizations officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some experiential, academic and recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees.

Parental Consent *

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill and I hereby give my consent to have my child(ren)treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that the program will provide no medical insurance for such treatment, and that the cost thereof will be at my expense. I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions.

Photo Release *

I hereby give permission for my child to be photographed during The Genius Project STEM Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of The Genius Project and its affiliates.

Transportation Release *

I hereby give permission for the transportation of my child for official The Genius Project Fieldtrip by modes of transportation agreed to by the camp organizers.

Check to receive camp information via email.

Parent information Meeting: Saturday, June 1, 2019 at 12:00 PM

For Questions, please call (909) 229-1956 or email simmons6197@gmail.com

Past and Present Sponsors

A2MEND

California State University Los Angeles Charter College of Education

Western University of Health Sciences

Elon Group LLC

Walmart