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Start Your STEM Center Enrollment

Community Learning Center - Intake Form

First Name *

Last Name *

Phone *

Email *

ZIP code *

Age *

School Status *

Select

Currently Enrolled in School
Not Currently Enrolled in School - High School Graduate
Not Currently Enrolled in School - College Graduate
Not Currently Enrolled in School - Vocational/Technical School Graduate
Not Currently Enrolled in School - Other (please specify)
Pursuing High School Diploma/GED
Completed High School Diploma/GED
Pursuing College/University Degree
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Vocational/Technical Training
Other (please specify)
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Name of the school where you are currently enrolled: *

If "Other" was selected above please specify your situation below.

Do you have work experience? *

Yes

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How many years of work experience do you have? *

Select

Less than 1 year
1-2 years
3-5 years
6-10 years
11-15 years
16-20 years
21-25 years
26-30 years
31-35 years
More than 35 years
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What technical skills are you interested in developing? *

Digital Literacy

Software Development

Cybersecurity

Digital Marketing

Drones

3D Printing

Artificial Intelligence

Who referred you?

Select

Deborah T.
Dee M.
Sean'Jerrion C.
Elias B.
Adamari N.
Lucid
Melvin V.
Shannon R.
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