After School Program Sign Up

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

* Indicates required field

Student Name *

First

Last

Age *

Gender *

Date of Birth *

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? *

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

Allergies *

If yes, explain: *

Physical handicaps *

Asthma *

If yes, explain: *

Name family physician/practice *

In case of emergency please call: *

First

Last

family physician phone *

Phone Number *

type *

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? *

please list names of approved people: *

Payment Information

i would like to sign up for: *

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 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 *

Submit

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

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