* Required

Student First Name 𝘗𝘳𝘪𝘮𝘦𝘳 𝘯𝘰𝘮𝘣𝘳𝘦 𝘥𝘦𝘭 𝘦𝘴𝘵𝘶𝘥𝘪𝘢𝘯𝘵𝘦required

Student Last Name 𝘈𝘱𝘦𝘭𝘭𝘪𝘥𝘰 𝘥𝘦𝘭 𝘦𝘴𝘵𝘶𝘥𝘪𝘢𝘯𝘵𝘦required

Year of Enrollment (ano de inscripcion)*

For which school year are you applying?

current year ('25-26)

Current School (Escuela actual)required

Grade as of Sept. 2025 (grado a septiembre 2025required

Date of Birth mm/dd/yy (Fecha de nacimiento)required (mm/dd/yyyy)

Parent - Guardian Name (Nombre del Padre de Familia / tutor legal)required

Relationship to Student (La relacion con el estudiante )required

Email Field (Su correo electronico)required

Address (direccion)required

City (ciudad)required

State (Estado)required

Zip (codigo postal)required

Day Phone (Telefono de dia)required

Evening Phone (Telefono de la tarde)required

Cell Phone (Telefono celular)required

When applying for multiple children in your household for the lottery please submit a separate application for each child.

Cuando solicite varios ninos en su hogar para la aplicacion, presente una solicitud por separado para cada nino/a.

ADDITIONAL (Adicional)

STEMCivics is a free public school that is open to all residents of New Jersey, regardless of race, religion, gender, national origin or disability of the students or the parents/guardians. (STEMCivics es una escuela pública gratuita que está abierta a todos los residentes de Nueva Jersey, independientemente de la raza, religion, genero, origen nacional o discapacidad de los estudiantes o los padres / tutores)

PARENT/GUARDIAN SIGNATURE

Parent/Guardian Signature (La firma del Padre/ Tutor legal)required

Date (La fecha de hoy)required (mm/dd/yyyy)

Please send a confirmation email to the address below*: