ESD Girls in Engineering Academy Application

Girls in Engineering Academy 2023 - Single Page

"*" indicates required fields

The application deadline is May 1, 2023. Applications will be considered as they are received during the application timeline. Students will be notified of a decision after May 1, 2023. Decisions will be based on the student’s essay, recommendations, and school transcript grades. All interested students are encouraged to apply.

NOTICE: A down payment of $100 will be required to submit this application. Any student not accepted into the GEA program will be refunded their down payment. Please have these forms prepared before starting this application:

NEW Students:

2 letters of recommendation (download form here)
most current grade transcript
student essay (download criteria here)
insurance information
medical history information

RETURNING Students:

most current grade transcript
insurance information
medical history information

General Information

Application Year*

Student Name*

First Middle Last

Student Date of Birth*

United States Citizenship*

Student is a U.S. Citizen

Student is NOT a U.S. Citizen

T-Shirt Size*

Student Address*

Street Address Address Line 2 City State ZIP Code

Student Email

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Race

Select all that apply.

Alaska Native

Asian

Black or African American

Native American

Native Hawaiian or Pacific Islander

White

Disability Status

Select all that apply

Hearing Impairment

Visual Impairment

Mobility Impairment

Other

Other Impairment

Please list other impairment, if applicable.

Primary Contact

This contact will be used for any information sent outside of the Remid texting app.

Parent 1 Name*

Prefix First Middle Last Suffix

Parent 1 Relationship to the Student (i.e. mother, father, grandparent, etc.)*

Parent 1 Address*

Street Address Address Line 2 City State ZIP Code

Parent 1 Email*

Parent 1 Cell Phone*

Parent 1 Home Phone

Secondary Contact

Parent 2 Name

Prefix First Middle Last Suffix

Parent 2 Relationship to the Student (i.e. mother, father, grandparent, etc.)

Parent 2 Address

Street Address Address Line 2 City State ZIP Code

Parent 2 Email

Parent 2 Cell Phone

Parent 2 Home Phone

Student Academic Information

School Name (2023-2024 School Year)*

Please include name and city of the school you will be attending beginning in the Fall of 2023.

Current Letter Grade Average or GPA*

Grade Level (2023-2024)*

Expected Year of High School Graduation*

Most Recent School Transcript*

An official school transcript is required before applications will be considered.

Drop files here or

Max. file size: 256 MB.

Recommendations (Year 1 only)*

Two recommendations (downloadable below) from a current teacher, guidance counselor, or principal are required. They may be uploaded here or emailed to gea@esd.org.

I will upload here.

Both forms will be emailed to gea@esd.org with the student name in the subject line of the email

DOWNLOAD TEACHER RECOMMENDATION FORM (Word Doc)

Recommendations Upload

Drop files here or

Max. file size: 256 MB.

Activities*

Please list any school activities that you have participated in, along with the date(s) of participation.

Student Essay*

Please explain why you want to participate in the Girls in Engineering Academy, how this program can help prepare you for a future career in engineering, and what you hope to gain from the experience. Your essay should be 150-200 words.

Image Consent and Release

I hereby grant permission for videographic, photographic or audio recording of the Student’s participation in activities, programs or functions sponsored by The Engineering Society of Detroit (ESD) Girls in Engineering Academy (GEA) and its affiliates, and for the use and distribution of such videos, photographs, and recordings by or with the consent of ESD/GEA, its university partners, for promotional and educational purposes. I further consent to the Student's name being used in connection with these recordings. I understand that all such recordings, in whatever medium, shall remain the property of The Engineering Society of Detroit. I release the Engineering Society of Detroit from liability for any violation in connection with this use of the recordings.

I have read and fully understand the terms of this consent and release.

Non-Agreement

I do not wish to have my child photographed or videotaped during the GEA Program.

Parent/Guardian Name*

Full name of parent or guardian signing this form.

Medical Treatment

Parent or Guardian Name*

Please indicate name of parent or guardian filling out this form.

Good Health and Responsibility*

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

Medical Matters*

Of the following statements pertaining to medical matters, I understand that I may sign only those in accordance with my wishes.

Emergency Medical Treatment

In the event of an emergency, I hereby give permission to transport my child to a hospital and/or Urgent Care Facility for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.

Emergency Contact Name*

In the event of an emergency, please call this person

Emergency Contact Phone Number*

Emergency Contact Relationship to Student*

Alternate Emergency Contact*

Alternate Emergency Contact Phone Number**

Alternate Emergency Contact Relationship to Student*

Student's Doctor*

Doctor Phone Number*

Student Health Insurance Provider Name*

Insurance Policy Number*

Insurance Group Number*

Medication

My child is NOT taking any medications.

My child is taking medication at the present time.

My child will bring all necessary medications and label them appropriately.

Medications

List names and medications and concise directions for see that the child takes such medications, including dosage and frequency of dosage.

Special Medications

Please list any special medications—including those for mental health—that staff should be aware of.

Medication Consent

I consent to prescription or non-prescription medication being administered to my child ONLY when the situation is life threatening and emergency treatment is required.

Chronic or Existing Medical Problems

(diabetes, asthma, seizures, etc.)

Allergies

Please list any allergies to medications, foods, dairy products, peanuts, fish, plants, insects, etc.

Immunizations

Please list the date of last tetanus/diphtheria immunization.

COVID-19 Vaccination

Has your child been vaccinated for the COVID-19 virus

Yes

COVID Release and Waiver*

The Engineering Society of Detroit (ESD) Girls in Engineering Academy (GEA) values public health and student safety.

The undersigned attendee acknowledges the role everyone plays in community health. Attendees are required to follow all state, local and GEA requirements related to public health and social distancing, and the undersigned agrees to follow CDC and other health and safety guidance throughout the course of the event. While this is a requirement that is placed on all attending and we will endeavor to achieve full compliance, we recognize it is not realistic for GEA to ensure that each and every attendee complies as fully as required.

The undersigned attendee acknowledges that an inherent risk of exposure to COVID-19 exists in any place where people are or have been present, including involvement. By participating in the ESD Girls in Engineering Academy, the undersigned voluntarily assumes all risks, including that related to exposure to COVID-19, and hereby releases and agrees not to hold the The Engineering Society of Detroit, Girls in Engineering Academy, or any of their respective affiliates, directors, officers, employees or volunteers liable from any illness or injury sustained in connection with participation in the event.

I agree to the COVID Release and Waiver

Parent Signature*

I acknowledge and confirm that I am the parent or duly authorized guardian of the participating student named above, with full authority to acknowledge and accept the terms of this COVID Release and Waiver on behalf the participating student, and do so by signing below.

Parent/Guardian Consent and Release Form

Student Name*

The name of the student referenced in the consent below.

Parent/Legal Guardian Name*

The name of the parent/legal guardian referenced in the consent below.

Consent*

I, the Parent or Guardian of above named student (the “Student”), hereby give my consent to the Student’s participation in the Program, including activities, programs, sessions or functions which may involve the use of hand tools, as well as visits to universities, companies and facilities, other offices and locations arranged by The Engineering Society of Detroit (ESD) Girls in Engineering Academy (GEA) or by mentors provided by or through ESD/GEA, and virtual engagement. I understand that the Student may be walking, taking a bus or traveling by other means to these locations, and that the students will be accompanied by GEA instructors at those locations.

In furtherance of the permission granted by me and to the Student for the Student’s participation in the GEA program, and in consideration of the possibility that GEA may allow the Student to participate in the Program, I, the Parent or Guardian of the Student, to the extent permitted by law, do hereby:

(1) assume any and all risk and liability for losses or damages to property and for damages, injuries or death which may arise in connection with travel to or participation in activities, programs, sessions or functions sponsored by ESD/GEA or its affiliates, and hereby, for the Student and for myself and our heirs, executors, administrators, successors and assigns, do release and discharge The Engineering Society of Detroit and each of its affiliates, and any and all mentors provided by or through ESD/GEA, including officers, directors, employers, employees, volunteers, university partners, predecessors, successors, representatives and assigns of any of the foregoing, from any and all claims, actions, and liabilities arising from or relating to participation in activities, programs, sessions or functions sponsored by or through ESD/GEA or its affiliates, including travel to and from such activities, programs, sessions or functions;

(2) permit ESD/GEA and its affiliates to survey the Student about the program’s impact and to publicly release aggregated survey results, and authorize and permit ESD/GEA and its affiliates to provide copies of this Consent Form to others as ESD/GEA or its affiliates deem necessary or appropriate; and

(3) acknowledge that the Student is not guaranteed an opportunity to participate in the ESD Girls in Engineering Academy and that no commitment is being made that the Student will have such an opportunity, and agree that ESD/GEA may, at its sole discretion, suspend, dismiss or discontinue the Student's participation in the program at any time, including circumstances in which the Student’s team or affiliate leaders believe that the Student’s behavior or engagement does not meet expectations, is disruptive or is less than appropriate for the Student or other students to benefit from the program.

(4) consent and agree that should ESD/GEA or any of its mentors believe that the Student may be a danger to him or herself or others, or a victim of abuse, bullying, neglect or other such difficulties, ESD/GEA may report this concern and the circumstances giving rise to the concern to the Student's school, guidance counselor or other authorities, as ESD/GEA may determine appropriate in its discretion, whether or not required to do so by law.

(5) consent and agree that ESD/GEA and its instructors, volunteers, mentors and employees may continue to stay in communication with the Student between or following the completion of the individual program sessions.

(6) ) grant permission for ESD/GEA to track the educational and employment history and status of the Student following the Student’s participation in the GEA program and to obtain student transcripts for that purpose from educational institutions attended by the student upon presentation of a copy of this document to such institutions.

(7) consent and agree to the execution of any and all documentation and/or consent documentation electronically with ESD/GEA.

(8) consent and agree that this consent and/or any other documentation between Parent or Guardian of the Student and ESD/GEA shall be subject to and governed by the laws of Michigan and agree that the courts of the State of Michigan shall have the exclusive jurisdiction to hear and determine any and all disputes.

On behalf of Student, myself and my spouse (if any), I release, indemnify and hold harmless The Engineering Society of Detroit and its directors, officers, employees, agents and volunteers, including university partners, from and against all claims, causes of action, demands, liabilities, damages or costs (including attorneys’ fees), and agree not to make any claims or demands against ESD or the other released parties, relating to or arising out of Student’s participation in the ESD GEA program, including, but not limited to, those based on bodily injury, illness, property loss or property damage.

I have carefully read the foregoing consent and release and know and understand the contents thereof. I sign this consent and release voluntarily as our own free act with knowledge of its significance and intend to be legally bound thereby.

I confirm, agree to and affirm the above.

Parent Signature*

By signing below, parent digitally signs this consent.

Student Pick-Up

Authorized People

The following individuals are authorized to pick up my child from the GEA program. They must provide photo ID on site. Please list names.

Additional Comments

Please include any additional information you believe would be helpful to us in reviewing your application.

Full Name of Signer

Please list your full name and sign below.

Signature*

I, the undersigned, agree that I have filled out this online form truthfully and to the best of my ability.

Program Fees

The GEA program cost from June 2023 through May 2024 is $300. $100 minimum is due at the time of application, with an additional $100 due on May 1, 2023. The balance is due on the day the summer program begins in June 2023. For any new students not admitted to the program, all program fees will be promptly refunded..

The program fee for the Girls in Engineering Academy will cover the cost of instructional materials and STEM kits and supplies.

Multiple Child Discount

For those families with more than one child in GEA at the same time, we offer $100 off per child. If you are enrolling more than one child, please check the box below and choose the $200 payment option for each child.

I have multiple children in GEA

Wayne-Westland/Zonta Club Financial Aid Scholarship

Students must be a current Wayne-Westland student or pre-selected from Zonta Club. Application involves creating a short video (256Mb maximum). The video should include your name, why you are interested, and showcase a STEM project you worked on or a STEM field you are interested in.

Student attends Wayne-Westland and is uploading a scholarship application here

Scholarship Upload

Upload your scholarship application here. Maximum 256 Mb total.

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Billing Email

Payment Amount*

The program fee total is $300, with $100 minimum due at the time of application. Please indicate how much you would like to pay now. NOTE: if you have more than one child currently in the program, there is a $100 discount.

Total

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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