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NC A&T Wildcats Coding Camp
Appication Form
If enrolling more than one child from the same family/household, please complete a separate application form for each child.
Child Information
Today's Date (mm/dd/yyyy)
Child's Full Name
Child's Date of Birth (mm/dd/yyyy)
Home Street Address
Address
Address 2
City
State
Postal code
Child's Grade Level (just completed)
3rd Grade
4th Grade
5th Grade
Child's School (currently enrolled)
Child's Race (select all that apply)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Other
Child's Ethnicty
Hispanic
Non-Hispanic
Child's Gender
Male
Female
Non-binary / third gender
Prefer not to say
What is your child's Reading Proficiency level
Below Grade Level
At Grade Level
Above Grade Level
Don't Know
What is your child's math proficiency level?
Below Grade Level
At Grade Level
Above Grade Level
Don't Know
Is your child an English Language Learner? (English is not their first language)
No
Maybe
Yes
Please list any languages your child speaks at home.
Does your child receive or qualify for free/reduced price lunch at school during the academic school year?
Yes
No
Does your child have health insurance?
No
Yes; if yes, please indicate the health insurance carrier
Has your child ever qualified for an Individual Educational Plan (IEP) or 504 plan?
No
Yes
Don't Know
What are some strategies that our team can use to best support your child's learning throughout the program?
Does your child have any allergies or health conditions of which we should be made aware? If yes, what?
Is there anything else that you would like to share about your child?
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