Teacher Mentorship Program Registration Form

YSA Teacher Mentorship Program

The Young Scientist Academy will host the Teacher Mentorship Program will take place during the Summer of 2024 and the 2024-2025 Academic Year. The summer portion will take place during the following dates: June 28 (Orientation), July 8-12, July 15-19, and July 22-25. Most days will include a student program portion in the morning, where teachers and YSA staff will lead students through lessons, and a teacher mentorship portion in the afternoon, where YSA staff will mentor teachers in how to implement YSA lessons.

Teachers will gain an in-depth understanding of how to implement YSA programs in their school and pair it with existing curriculum standards. Participants will receive a $1500 stipend split up over the course of the entire mentorship program ($1000 during the summer, $500 during the academic year).

Teachers in Title I schools will be prioritized, and successful candidates will be expected to recruit their current students to apply for YSA Student Summer Program.

Application deadline: May 22 at 11:59pm

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

Resume

* Indicates required field

Student Name *

First

Last

Student Gender *

Student 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? *

YSA Summer Program Registration

Our summer programs are currently offered to students in grades 5 and above. Note that making the selections below does not guarantee a spot for your child in the program. We will always do our best to get your child in the program, but if space is not available then your child will be placed on a waiting list.

I would like to register my child for the following week(s): *

Week 1: July 8-12 Week 2: July 15-19 Week 3: July 22-25

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 Disability? *

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 family physician/practice *

Family physician phone *

In case of emergency please call: *

First

Last

Emergency Phone Number *

List names and phone numbers 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.

I agree to allow the Young Scientist Academy to use my 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. *

Agree

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