Project Determination

Registration Form

Project Determination offers students in 5th & 6th grades a fun, afterschool environment to
explore the world they live in by infusing visual arts, science, technology, engineering, and mathematics
(STEM) together. Students will participate in hands on science inquiry experiences, have opportunities to
showcase the projects that they create and discover their own aspirations. Project Determination will meet
for seven consecutive Mondays from 3:30pm to 6:00pm, with a culminating event on December 6, 2010.

Space is limited to 25 students. A waiting list will be maintained, and applicants are accepted from the waiting
list as space becomes available.

Please print clearly or type:

Student Name: _________________________________________________________

Mailing Address: ________________________________________________________

City ____________________________________State __________ Zip____________

Gender M ___ F___ Date of Birth (MM/DD/YY) ______/______/_____

Current grade in school_______ School Name and address ___________________________________

Ethnicity- This information is requested so we may report statistical data regarding our participants to the State of Illinois
and/or other program funders. Only aggregate date will be shared. Summaries will not contain individual information.
Please pick one or more from list below

□ Hispanic or Latino(a) □ Black or African American

□ American Indian or Alaskan Native □ Native Hawaiian or other Pacific Islander
□ Asian □ White

Parent/Legal Guardian _________________________________________________________________

Phone Home: _________________________ Cell_____________________ Work__________________

Parent/Guardian email _________________________________________________________________

How did you hear about Project Determination?

___________________________________________________________________________________

Signature
Your signature indicates that you support your child’s full participation in Project Determination. You will also provide
arrangements to and from IMSA Chicago Field Office. Your signature gives permission for your child’s photograph to be
taken and used for educational and promotional purposes by IMSA.

Parent/Guardian Signature __________________________________________ Date ______________

Please email or fax the registration form to:

Latasha Battie, Field Office Coordinator for Chicago,
Phone: 630-723-8096
Fax: 312-256-9297
E-mail: lbattie@imsa.edu