YSA Program Registration Form

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

* 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? *

Will your child require transportation? *

No Yes - pickup only Yes - drop-off only Yes - both pickup and drop-off

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:

I would like to register my child for the following program: *

Code Niñas @ GLOW - Wed 4-5p, starting mid October Science for Refugee Youth* Afterschool Science - Waiting List Ambassador Science - Waiting List General Science - Waiting List Latinx Science - Waiting List

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 *

In case of emergency please call: *

First

Last

family physician phone *

Phone Number *

type *

Is there anyone else other than yourself approved to pick up your child? *

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), 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.

Digital signature of parent or guardian *

relationship to student *

date *

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.

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