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Home
About
Mission
Our Team
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In the News
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Programs
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YSA REGISTRATION FORM
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:
*
Male
Female
Genderqueer/Non-Binary
I'd prefer not to disclose
Date of Birth
*
MM/DD/YYYY
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 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. * denotes approval is required from YSA to be eligible to apply to these programs:
I would like to register my child for the following program:
*
Youth Research Collective (formerly Open Lab)
Girls Who Code/Code Girls (Girls only)
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
*
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
*
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.
relationship to student
*
date
*
MM/DD/YYYY
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
No
Student Name
*
First
Last
Parent or Legal Guardian Name
*
First
Last
Relationship to Student
*
Digital Signature
*
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.
Date of Signature
*
I agree to receiving marketing and promotional materials
*
Submit
Home
About
Mission
Our Team
Sponsors
In the News
YSA Summit
Programs
Contact
Donate