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KidsCode Registration Form
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Contact Information
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Step
1
of 3
First Name
*
Please enter student first name.
Last Name
*
Please enter student last name.
Birth Date
*
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Please enter student's birth date (mm/dd/yyyy)
Gender
*
Male
Female
Other
Please choose gender.
Current Grade
*
4th
5th
6th
7th
8th
9th
10th
11th
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School Name
*
Home School
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Academy of Holy Names
Academy Prep of Tampa
Adams
American Youth Academy
Apollo Beach
Armwood
Bailly
Barrington
Bayaan Academy
Benito
Blake
Bloomingdale
Booker T Washington
Bowers/Whitley
Brandon
Brooker Creek
Brooks DeBartolo Collegiate
Broward
Buchannan
Buffalo Creek
Burnett
Cahoon
Cannella
Carver Center
Center Academy
Chamberlain
Channelside Academy
Clair Mel
Cleveland
Coastal Connections Academy
Collins
Corbett
Cork
Cutting Edge Learning Academy
Cypress Creek
Davidson
Depaul
DeSoto
Doby
Dowdell
Durant
East Bay
Egypt Lake
Eisenhower
Farnell
Florida College
Florida Virtual School
Folsom
Foster
Franklin
Freedom
Friendship Academy
Friendship Christian Academy
Gather
Gary
Giunta
Graham
Hifz Academy
Hillsborough
Hillsborough Academy
Hillsborough Virtual
Hunters Green
Icon Prep
Idea HOPE
Imagine School
Immanuel Lutheran
Jefferson
Jennings
John Long
Just
Kids Community College
Kimbell
King
Lake
Lake Magdelene
Leadership Academy
Lee
Legacy Prep
Lennard
Leto
Lewis
Liberty
Lincoln
Livingstone
LLT
Lockhart
Lomax
Lopez
Lowry
Macfarlane Park
Madison
Manatee School for the Arts
Mango
Maniscalco K-8
Mann
Marshall
Martinez
McDonald
McLane
Memorial
Mendem Hall
Middleton
Mintz
Monroe
Mt. Calvary
New Life Tabernacle Academy
Newsome
North Tampa Alternative
Northwest
Orange Grove
Palm River
Paxen
Phillip Shore
Plant
Plant City
Potter
Progress Village
Randall
RCMA
Riverview
Robinson
Rodgers
Roland Park
Rompelo
Ruskin
Seminole
Seminole Heights
Sessums
Shields
Sickles
Simmons
Sligh Middle
South County
Spoto
Springhead
St Joseph
St Peter Claver
Steinbrenner
Stewart
Strawberry Crest
Sulphur Springs
Summerfield
Sunlake Academy
Tampa Bay Christian
Tampa Bay Tech
Tampa Palms
Tampa Prep
Terrace Community
Terrell Sessums
Thompson
Thonotassa
Tinker
Tomlin
Trinity SFC
Turkey Creek
Twin Lake
Universal Academy of Florida
USF Patel
Villa Madonna
Village of Excellence
Walker Middle Magnet
Watergrass
Waters
Waterset Charter
Webb
Westchase
Westshore
Wharton
Williams
Wilson
Windy Waters
Winthrop Charter School
Woodmont
Woodson
Young
Select your school.
Type your school name if it is not on the list:
*
Referring Agency (Cohort)
*
Choose Not Applicable if none apply to you
Not Applicable
Social Media (Homeschooler)
Jackson Springs Community Center
Higher Calling Ministries
Other (someone referred me, but they aren't listed)
Select organization that referred you
Please type the name of the organization or person who encouraged you to sign up.
*
Current Class Day Availability
*
Tuesdays (5:00 PM- 6:00 PM) (ONLINE)
Wednesdays @ Temple Terrace Library (5:00-7:00PM) (IN-PERSON)
Wednesdays @ Jackson Springs Community Center (6:30-8:30PM) (IN-PERSON)
Tuesdays @ St. Luke AME Church (6:30-8:00) (IN-PERSON)
Questions? Please email Pingraham@computermentors.org.
Student Cell Phone Number
Please enter student cell phone number
Student Email Address
Email
Confirm Email
Please enter student email address
Hispanic
*
Yes
No
Race
*
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
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Two or More Races
I Decline
Next
Parent/Guardian Name(s)
*
Enter parent/guardian name(s).
Parent/Guardian Cell Phone Number
*
Please enter your cell phone number
Parent/Guardian Email Address
*
Email
Confirm Email
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Address
*
Our programs serve only the residents of Hillsborough county
City
*
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State
*
FL
GA
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ZipCode
*
Please enter your zipcode.
Free or Reduced Price Lunch
*
Free or Reduced Price
Full Price
Please select your free and reduced lunch status
Next
I, ___ the legal parent or guardian of ___ give permission for his or her participation in the TeenTech/KidsCode Program. I further attest/certify that the information contained within this application is true to the best of my knowledge. I have read the authorizations and release of liability statements on the back of this form and understand all of its terms. I execute it voluntarily and with full knowledge of its significance.
*
I Agree
Please check appropriately.
In consideration of permission for my student’s participation in the TeenTech/KidsCode Program, I do hereby release and discharge Computer Mentors Group, Inc., its agents, officers, and employees from any and all claims, demands, grievances, and causes of action of every kind whatsoever, including, but not limited to, all liability for property damages and personal injury of every kind as part of said program. I agree to indemnify and hold harmless Computer Mentors Group, Inc., TeenTech/KidsCode Program, Board members, officers, employees and volunteers from any claims, liability, loss or expense, including reasonable attorney’s fees, suffered by any of the foregoing indemnities and arising out of a claim related directly or indirectly to my student’s enrollment and participation in the TeenTech/KidsCode Program. I __ understand that this hold harmless agreement also requires that Computer Mentors Group, Inc. is indemnified from any losses or damages resulting from the acts or omissions from any guest, participant, visitor or other person participating in the TeenTech/KidsCode Program herein referred to.
*
I Agree
Please check appropriately.
Photography Consent Form / Release: I, __,parent or official guardian of __, hereby grant permission to Computer Mentors Group Inc. to take and use: photographs and/or digital images for use in news releases and/or educational materials. These materials might include printed or electronic publications, Websites or other electronic communications. I authorize the use of these images without compensation to me. All negatives, prints, digital reproductions shall be the property of Computer Mentors Group, Inc.
*
I Agree
Please check appropriately.
Signature (Parent/Guardian)
*
Clear Signature
Attention parents! Classes are conducted online, and require access to a computer and the internet.
Today's Date
*
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Please enter today's date.
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