Project Lead The Way Summer STEM Program

Parent/Guardian Name *

First Name

Last Name

Student Name *

First Name

Last Name

Home Address (must be within City of Homestead limits) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

I give permission for my child to be photographed during program activities. *

YES

NO

Residency Verification: You must provide a recent utility bill (water, electric, gas) showing your name and address within the City of Homestead limits. *

I confirm that I will provide a utility bill as proof of residency within the City of Homestead limits.

Financial Eligibility Verification (select one): *

I will provide documentation showing my child qualifies for free or reduced school lunch program.

I will provide a copy of my child's Medicaid card.

Would your child need transportation to access the program at 13350 SW 288th St, Homestead, FL 33033? *

YES

NO

I certify that all information provided in this application is true and correct to the best of my knowledge. I understand that providing false information may result in disqualification from the program. *

YES