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    YOUNG SCIENTIST ACADEMY REGISTRATION FORM

    Please complete the YSA Registration and Photo Consent forms below. For questions please contact Dr. Rob at rob@youngscientistacademy.org.
    Student Details
    MM/DD/YYYY

    YSA Program Registration
    Our programs are currently offered students in grades 3-8 students. Note that making the selections below does not guarantee a spot for your child in the program, and that in some cases . 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. * denotes approval is required from Dr Rob to be eligible to apply to these programs:


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

    Acknowledgement of Registration Conditions
    I understand, agree and acknowledge that my child’s participation is not the responsibility of the Young Scientist Academy (YSA), Voyage, El Cuerpo or the Harrelson Center, 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 have read the YSA COVID-19 Health and Safety Standard Operating Procedures and agree to abide by the protocols described in the document. I expressly agree to assume any such risks on my behalf and that of my child. 
    Parent or legal guardian should state their full name which will serve as a digital signature to acknowledge their understanding of the terms and conditions of registering for YSA programs.
    MM/DD/YYYY

    YSA Photo/Video Consent Form 2022
    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. ​
    Parent or legal guardian should write their full name below to acknowledge consent for YSA to take your child's image. By signing I agree to grant YSA permission to photograph and video my child, and publish these images on the YSA website and affiliated social media platforms.

Submit
Picture
Young Scientist Academy // 501(c)(3) EIN 81-4999928
Suite 420, 20 N 4th Street
Wilmington, NC 28401
Ph: (910) 386-1867
  • Home
  • About
    • Our Mission
    • Our Space & Facilities
    • Our Team
    • Our Impact
  • Programs
  • Calendar
  • Contact
  • Donate