Coding Bootcamp Registration Form Registration: March 24, 2025 to April 25, 2025 Coding Bootcamp Application - High School Students Contact Information Participant's Name * Participant's Name First First Last Last Participant's Birthday * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Participant's Email * Are you a resident of Clayton County? * Yes No Race * WhiteBlackHispanic or LatinoAsianNative American or AlaskanHawaiian or Pacific Islander Is English your primary language: * Yes No If no what is your primary language? * Participant's Mobile Number * Alternate Phone Number Are you currently enrolled in school? * Yes No What school do you attend? School Name * What year of school are you in? * Are you currently employed? * Yes No If Yes, Where? Company Name * Job Title * How long have you been working at your current job? * Parent/Guardian Information Name * Name First First Last Last Email * Mobile Number * Alternative Phone Is English your primary language? * Yes No Are you currently employed? * Yes No How many people are in the household? * Annual Income (W2 1099 Unemployment Retirement) * $ Other Sources of Income (Select all that apply) Spousal Support Child Support OtherOther Emergency Contact Information Name * Name First First Last Last Relation to Child * Phone (Day) * Phone (Evening) * Is the child taking any medication? * Yes No If yes, what kind? * Does the child have any of the following, and if so explain: Allergies, Asthma etc Does your child have a communicable disease or condition which may prove to be a risk to others * Yes No I have read and understand the program eligibility requirements and application deadline: * I agree ID/License * Drop a file here or click to upload Choose File Maximum file size: 134.22MB Last 2 Check Stubs * Drop a file here or click to upload Choose File Maximum file size: 134.22MB Upload (2) utility bills * Drop a file here or click to upload Choose File Maximum file size: 134.22MB Applicant Signature * signature keyboard Clear Initial here if you do not want pictures of your child used for this purpose. Parent/Guardian Signature * signature keyboard Clear CAPTCHA Submit Start Over If you are human, leave this field blank.