Summer Camp 2023 Math and Movement Mini-Academy 4th-6th

The Math & Movement Mini-Academy will take place on Friday, June 30. A session for rising 4th - 6th graders will be from 1:00 - 4:00 pm. This Mini-Academy will take place at the MC-100 building on ORAU's campus.

I would like to register my child for the Math & Movement Mini-Academy.

Yes

No

Registration Deadline: June 2, 2023

If you are registering more than one child, please submit a separate registration for each child.

Student Information

First Name:	First Name:
Middle Name:	Middle Name:
Last Name:	Last Name:
Please provide the preferred first and last name for your student's name badge.	Please provide the preferred first and last name for your student's name badge.

What is student's current grade?

3rd

4th

5th

Parent/Guardian Information

Please use this format for phone number: 123-456-7890. Put N/A, if you don't have a home phone or cell phone.

Parent/Guardian First Name:	Parent/Guardian First Name:
Parent/Guardian Last Name:	Parent/Guardian Last Name:
Parent/Guardian's daytime phone number:	Parent/Guardian's daytime phone number:
Parent/Guardian Cell Phone Number:	Parent/Guardian Cell Phone Number:
Parent/Guardian Home Phone Number:	Parent/Guardian Home Phone Number:
Parent/Guardian E-mail Address:	Parent/Guardian E-mail Address:

Please provide the following information on the student's school and achievement.

School Information

School Name:	School Name:
School City:	School City:
School State:	School State:
School Zip Code:	School Zip Code:

Grades help us to know how a student is doing in school which aids us in planning the Academy's activities.

Grade student received in May 2023 or on last grade report. 4,3,2, and 1 are available options for standards-based classroom.

A
B
C
D
F
4
3
2
1
N/A, if grades not given

Demographics

The following demographic data is used only for ORISE program participant recording.

Is the student a U.S. Citizen?

Yes

No

If no, what is the student's citizenship?

Gender

Female

Male

Prefer not to answer

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

Other Race

Decline to answer

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

I choose not to respond

Please complete and upload the Parental Consent Form and upload the front and back of your insurance card. You can access the form at this link.

Page one of Parental Consent Form	Page one of Parental Consent Form
Page two of Parental Consent Form	Page two of Parental Consent Form
Front of Insurance Card	Front of Insurance Card
Back of Insurance Card	Back of Insurance Card

Thank you for registering your child for the Math & Movement Mini-Academy!

When you hit SUBMIT, you should receive a confirmation screen and email (if email address was provided).

If you do not receive a confirmation screen, please review the application for any red error messages and correct/complete all entries and hit SUBMIT again.

For technical assistance, please contact us at K12@orau.org or Pai Moua at (865) 250-2721.

Thank you.