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YOUNG SCIENTIST ACADEMY REGISTRATION FORM
"YSA Science & Technology Homeschool Program"
Indicates required field
Date of Birth
Parent/Legal Guardian Name
Best Phone Number
Homeschool Class Registration
My child would like to register for the following classes:
Innovation & Entrepreneurship Waiting List - $25 deposit (refunded if not selected)
Young Scientists in Training - Th 9-11a - $15 per week, paid monthly
Homeschool Science Waiting List - $25 deposit (refunded if not selected)
Please add my child's name to the Homeschool Science waiting list:
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".
A non-refundable application fee of $25 per child applies to all first time registrants.
I will be paying for the Homeschool class using:
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".
Please Specify if your child has completed any public of private school education.
What grade level will your child be in the 2019/2020 school year?
What grade level do you think your child can realistically complete? (can be the same or higher level as current grade level)
Relativeto their school level, how experienced is your child in science and mathematics?
No Experience At All
Please provide any other comments about your child's expectations or education history.
I agree and acknowledge that following official registration in the YSA Science Homeschool Program, 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 or 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
Young Scientist Academy // 501(c)(3) EIN 81-4999928
Suite 420, 20 N 4th Street
Wilmington, NC 28401
Ph: (910) 386-1867
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