Chem-E Camp Application

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Student Skills

List STEM related courses you have completed. *

List any and all coding languages you have experience with.*

Coding examples: C++, Python, MATLAB, etc.

Tell is about your interests and hobbies. Are you part of any student clubs or sport teams? Do you have any career/education goals?*

How do you see this camp benefiting you? What do you hope to gain from attending?*

Parent/Guardian Information

Parent/Guardian 1 Name*

First Name

Last Name

Parent Guardian 1 Email*

Parent/Guardian 1 Phone*

Primary Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Would you like to add on a second parent/guardian?

Yes No

Second Parent/Guardian Information

Parent/Guardian 2 Name

First Name

Last Name

Parent Guardian 2 Email

Parent/Guardian 2 Phone

Primary Address (if different from first parent/guardian)

Address Line 1

Address Line 2

City

State

ZIP Code

Additional Information

How did you hear about this camp? (Check all the apply)*

Social Media School Teacher/Staff Member Buffalo Prep Program STEP BEAM From another UB summer camp UB Faculty/Staff Community Event (ex: Girls World Expo, She Started IT, CSKids Day, etc.)

Other:

Please give us the name of one academic reference for this student (school counselor, staff member, teacher, etc). This person should be aware they are being listed as a reference. A letter of recommendation is not required for this camp but we may reach out to them.

Reference Name*

First Name

Last Name

Reference Title*

Ex: Guidance Counselor, Math Teacher, etc.

Reference Email*

Reference Phone*

Place of Employment*

Student Information

Student Skills

Parent/Guardian Information

Second Parent/Guardian Information

Additional Information