Sidewalk Science Registration Form

YSA REGISTRATION FORM

Sidewalk Science Registration

We are excited to offer Sidewalk Science during July and August. If you and your student are planning to attend any of the programs, please register below.

Please complete the YSA Registration and Photo Consent forms below. For questions please contact [email protected].

Student Details

* Indicates required field

Student Name *

First

Last

I identify my gender as: *

Date of Birth *

Parent/Legal Guardian Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Best Phone Number *

Parent Email *

What school does your child attend? *

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

Allergies or Asthma? *

Yes No

If yes, explain: *

Physical Handicaps? *

Yes No

If yes, explain: *

Dietary restrictions? *

Yes No

If yes, explain: *

Is your child up to date with his/her/their regular vaccine schedule? *

Yes No

If no, explain: *

Name of family physician/practice *

Family physician phone *

In case of emergency, please call: *

First

Last

Emergency Phone Number *

List names of anyone else other than yourself approved to pick up your child. *

Acknowledgement of Registration Conditions

required *

I agree

I understand, agree and acknowledge that my child’s participation is not the responsibility of the Young Scientist Academy (YSA), its employees, volunteers, officers, or agents. I affirm and agree that as parent/legal guardian, I will grant the approved supervisors, educators, volunteers 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 acknowledge that I expressly agree to assume any such risks on my behalf and that of my child.

Digital signature of parent or guardian *

relationship to student *

date *

YSA Photo/Video Consent Form 2024

Staff, board members, approved volunteers, student interns and/or hired photographers of Young Scientist Academy often take photographs and/or video for educational or publicity purposes. These images and videos may appear in YSA promotional materials or on our website and social media platforms.

Please note that websites can be viewed throughout the world, not just in the United States. This form is valid for five years from the date of signing.

May we use your child’s image(s) and video in publicity materials produced by YSA, including printed publications, digital films, in-house presentations and on our website and social media? *

Yes

Student Name *

First

Last

Parent or Legal Guardian Name *

First

Last

Relationship to Student *

Digital Signature *

Date of Signature *

I agree to receiving marketing and promotional materials *

Submit