Dare to Dream ESTEAM Summer Experience

Is the participant under 18 years old? * Yes
No

(If under 18) Parent's First Name

(If under 18) Parent's Last Name

Registrant First Name (point of contact) *

Registrant Last Name (point of contact) *

Email *

Address *

City *

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Zip Code *

Country none selected Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte D'Ivoire Cambodia Cameroon Canada Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Democratic People's Republic of Korea Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard & McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar(Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Ireland Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Réunion Réunion Sào Tomé And Príncipe Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Scotland Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia & South Sandwich Islands South Korea South Sudan Spain Sri Lanka St. Barthélemy St. Helena St. Martin St. Pierre & Miquelon Sudan Suriname Svalbard & Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu U.S. Outlying Islands US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wales Wallis & Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands

Telephone

Primary Language

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Alternate Phone

Is there anything we need to know or any accommodations that your child might require?

Legal Guardian Certification *

I am allowing my minor child/ren listed below to participate in the program listed above, which will be facilitated virtually by the Housing Opportunities Commission of Montgomery County (HOC). I hereby certify, under the penalty of perjury, that I am the legal guardian of the children listed in this Agreement, and that I have the authority to sign this Agreement on their behalf. I agree that participating in the program is a benefit to me and my children and, in consideration of this benefit, I am signing this Agreement on behalf of myself and my children.

I acknowledge receipt of HOC's Terms and Conditions for participation. *

Media Release Acknowledgment

HOC requires all participants to either accept HOC's Media Release ("Media Release") or to opt out of the Media Release. If you want to opt out of the Media Release, please complete this form. If you do not opt out, then by submitting this form, you are accepting the Media Release for yourself and the participants listed in this form.

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