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    YOUNG SCIENTIST ACADEMY REGISTRATION FORM:
    "YSA After-School Science & Technology Program"

    MM/DD/YYYY
    Emergency Medical History
    This information will be kept confidential and secure on file in case of emergency.

    ​Payment Information
    A non-refundable application fee of $25 per child applies to all first time registrants.
    ​Payment Options: 
    Payment for YSA programs can be made via Credit card, bank transfer, cash or check/invoice and instructions for payment will be provided following submission of the "YSA registration form".
    Credit card payments are made online through Quickbooks (3.4% surcharge applies). Customers will be invoices following submission of the "YSA Registration Form". Checks should be made payable to "Young Scientist Academy".
    ​​I agree and acknowledge that my child’s participation is not the responsibility of the Young Scientist Academy (YSA) or the Harrelson Center, its employees, officers, or agents. I affirm and agree that as parent/legal guardian, I will grant the approved supervisors, educators and chaperones from YSA the responsibility to supervise my child during YSA activities and field trips. I further agree and understand there are inherent risks attendant to these activities – including but not limited to personal injuries that may be sustained while participating in YSA activities.  I expressly agree to assume any such risks on my behalf and that of my child. I agree to pay the one time application fee (non refundable) of $25 and that program tuition is due before the start of each module session. I also grant YSA permission to photograph and video my child, and publish these images on the YSA website and affiliated social media platforms.
    MM/DD/YYYY
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Young Scientist Academy // 501(c)(3) EIN 81-4999928
Suite 420, 20 N 4th Street
Wilmington, NC 28401
Ph: (910) 386-1867
  • Home
  • DONATE
  • Code Girls
  • Programs
    • Afterschool Science Ambassadors Program (ASAP)
    • Youth CAUSE Initiative
    • Homeschool Science
    • Latinx Science Seminars
    • Virtual Experiences
  • About
  • Scholarships
    • Apply for a Scholarship