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YOUNG SCIENTIST ACADEMY REGISTRATION FORM:
"YSA After-School Science & Technology Program"
*
Indicates required field
Student Name
*
First
Last
Age
*
Gender
*
Male
Female
-
Date of Birth
*
MM/DD/YYYY
Parent/Legal Guardian Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Best Phone Number
*
Email
*
What school does your child attend?
*
Does your child require school pickup?
*
Yes
No
Emergency Medical History
This information will be kept confidential and secure on file in case of emergency.
Allergies
*
-
No
Yes
If yes, explain:
*
Physical handicaps
*
-
No
Yes
Asthma
*
-
No
Yes
If yes, explain:
*
If yes, explain:
*
Name family physician/practice
*
In case of emergency please call:
*
First
Last
family physician phone
*
Phone Number
*
type
*
-
Business
Home
Cell
are there any learning or emotional concerns you would like to share?
*
Is there anyone else other than yourself approved to pick up your child?
*
-
No
Yes
please list names of approved people:
*
Payment Information
i would like to sign up for:
*
-
3 days - $160/4 wk session
5 days - $200/4 wk session
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".
I will be paying for YSA with:
*
-
Credit Card
Check
Cash
Bank Transfer
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".
required
*
I agree
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.
signature of parent or guardian
*
relationship to student
*
date
*
MM/DD/YYYY
Submit
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