YSA Summer Program Application

Summer Program Application

Please complete the YSA Application 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? *

YSA Program Registration

Our programs are open to students in 5th grade and above. Please note that selecting a program does not guarantee enrollment. We will make every effort to accommodate your child, but if space is unavailable, they will be placed on a waiting list.

Summer Program Details
Our summer programs combine hands-on field experiences with interactive digital workshops. Students will learn data collection techniques and coding languages to design and conduct their own research projects.

Program Hours: 10:00 AM – 3:00 PM

I would like apply for my child to attend the following program(s): *

June 23 - 27 & June 30 - July 3 July 7 - 11 & July 14 - 18 July 21 - 25 & July 28 - Aug 1

Application Questions
The student should answer these questions.

If you could change one thing about the way science is taught in schools, what would it be? *

What is an important issue in the community that can be solved by using science? *

Why do you want to be in the program? *

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 requirements? *

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 Number *

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 2025

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 No

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