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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
*
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?
*
Will your child require transportation?
*
No
Yes - pickup only
Yes - drop-off only (spaces limited)
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:
*
Summer programs - Waiting list
Global Explorers - Science for Refugee & International Youth*
Open Lab - Science Squad - OPEN
Open Lab - Tech Team - OPEN
What days is your child available to participate in YSA programs (select all that apply)?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday morning
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
*
-
Business
Home
Cell
Is there anyone else other than yourself approved to pick up your child?
*
No
Yes
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
*
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 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
*
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
Our Mission
Our Space & Facilities
Our Team
Our Impact
Earth Day Summit
Programs
Calendar
Contact
Donate