Rotary District 7430 & STEM YEA Youth Explorer Academy

Mission to Mars · June 24–27, 2027

Student Registration

Four days and three nights at Kutztown University, at no cost to your family. This form takes about fifteen minutes. Nothing is saved until you press Submit at the end.

Questions? Registration@stemyea.com

* indicates a required answer

About you

The person filling in this form — a parent, guardian, teacher or club representative.

Your email * We will send a confirmation here, with a link to edit your answers later.

Your name *

Your relationship to the student *

Sponsoring Rotary Club * If you are unsure which club is sponsoring, ask the school or email us.

The student

Who is attending the Academy.

First name *

Last name *

Date of birth *

Gender *

Male Female

Race and/or ethnicity *

Select all that apply. We report anonymised totals to our sponsors.

Additional languages the student speaks Enter NONE if not applicable.

Student email * Enter NONE if they have none.

Student phone * Enter NONE if they have none.

Street address *

City *

State *

Zip *

School the student attends *

Current grade level *

Tee shirt size *

Will the student have a smart phone at the Academy? *

Yes No

Phones stay in dorm rooms during daily activities.

Computer access at home? *

Yes No

To be answered by the student: why do you want to attend STEM YEA? *

Health and medical

Read only by our Doctor and the STEM YEA Program Manager. Dining Hall Services are notified of any allergies or dietary restrictions.

STEM YEA has a full-time registered nurse present for the entire Academy, including overnight, as well as a medical director. For them to be most effective, they need some information about your child.

Does your child have any chronic or serious medical issues? *

Yes No

If yes, what are they?

Does your child take any medications? *

Yes No

If yes, what are they and for what medical conditions? Include the dose and when it is taken if you know it.

Does your child have any serious allergies? *

Yes No

If yes, what are they? Tell us here if your child carries an EpiPen or inhaler.

Does your child have any learning disabilities or behavioral issues? *

Yes No

If yes, what are they? This helps our faculty support your child, not screen them out.

Are there any other medical or health concerns that you would like to share with us?

Dietary restrictions * Allergies, intolerances, religious requirements — or enter NONE.

Other special needs * Anything our staff should know — or enter NONE.

Parent or guardian

Our first point of contact during the Academy.

Name *

Relationship to student *

Email * Enter NONE if they have none.

Phone *

Does the parent or guardian speak English? *

Yes No

If not, what language is spoken? * Enter NA if not applicable.

Backup emergency contact

Someone we can reach if the parent or guardian cannot be contacted.

Name *

Relationship *

Phone *

Commitments

Four agreements between the student, the family and STEM YEA.

The student will attend a meeting of the sponsoring Rotary Club after the Academy to share their experience. *

Yes No

The student and parent or guardian understand the student must attend the full four-day, three-night program. *

Yes No

The parent, guardian or sponsoring Rotary Club will provide transportation to Kutztown University on Thursday, June 24, 2027, and collect the student on the evening of Sunday, June 27, 2027. *

Yes No

The following will be scanned and emailed to registration@stemyea.com within two weeks of submitting this form: *

Signed waivers and permissions
Completed health and physical form

Yes No

Nothing is saved until you press Submit.

STEM YEA · a program of Rotary District 7430 www.stemyea.com