S.T.E.A.M. Enrollment FormPlease enable JavaScript in your browser to complete this form.Choose A Program *Mommy, Daddy and Me"Black Girls Code" Coding CampTechnovation GirlsCome Get Your BooksSolar CampMaking MeMoney MattersChild's Name *FirstLastBirthday *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Gender *MaleFemaleChild's School Grade *1st2nd3rd4th5th6th7th8th9th10th11th12thAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeChild's School *With whom is child living?MotherFatherBothLegal GuardianOtherMother's Name *FirstLastFather's Name *FirstLastLegal Guardian's Name *FirstLastThis Person's Name *FirstLastAddress (If Different From Child's)Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Work PhoneCell PhoneEmail Address *EMERGENCY CONTACT IF PARENTS CANNOT BE REACHED *FirstLastRelation To Child *Home Phone *Work PhoneCell PhoneChild's Name *PARENT/GUARDIAN CONSENT AND RELEASE: I grant my permission for my child to participate in the Detroit Impact Center Programs including all on-site and field trip activities. The Detroit Impact Center and those operating programs are authorized to consent to emergency medical treatment while this child is in the Detroit Impact Program. I hereby release, exonerate, and discharge Detroit Impact, Inc. and its officers, directors, representatives, employees, whether voluntary or employed from any and all liability, damages, actions, or causes of action for any injuries suffered by or medical emergency occurring to this child while enrolled in the Detroit Impact Program. In addition, I understand and agree that Detroit Impact and its officers or representatives will and are hereby authorized to make audio and/or video recordings of the program activities and to incorporate these recordings into public relations and advertising materials or otherwise and to license others to do the same in any manner of media whatsoever. *I agree to the above consent and releaseParent/Guardian Initials *Date *EmailSubmit