Summer Camp Sign Up

YOUNG SCIENTIST ACADEMY REGISTRATION FORM:
"YSA Summer Science Camp Program"

Payment for YSA programs can be made via credit card, PayPal, bank transfer, cash or check and customers will be invoiced for payment following submission of the registration form. Full payment will secure spot in our summer camps.

* Indicates required field

Student Name *

First

Last

I identify as gender: *

Date of Birth *

Parent/Legal Guardian Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Best Phone Number *

Email *

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

Allergies *

If yes, explain: *

Physical handicaps *

Asthma *

If yes, explain: *

Name family physician/practice *

In case of emergency please call: *

First

Last

family physician phone *

Phone Number *

type *

are there any learning or emotional concerns you would like to share? *

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

please list names of approved people: *

Payment Information

Prices below reflect the Early Bird Discount, full prices will apply after March 31, 2020.

I would like to sign up for (Check all that apply): *

YSA Summer Pass - $931 (all 7 weeks, 30% discount) Marsh Mud & Microbes - $153 (June 15-19) Aussie Wildlife & Traditions - $153 (June 22-26) Potions & Pyrotechnics - $153 (June 29 - July 3) Atmospheric Explorers I - $153 (July 6-10) Atmospheric Explorers II - $153 (July 13-17) Sea Turtle Science - $213 (July 20-24) Jellyfish & Ocean Drifters - $153 (July 27-31)

I will require before and/or after camp care: *

Not required Before camp only - $10/day (7.30-9a) After camp only - $10/day (4-5.30p) Before & after camp - $15/day

I would like to purchase a YSA Camp T-shirt: *

Select t-shirt size: *

A non-refundable application fee of $25 per child applies to all first time registrants.

Payment Options:
Payment for YSA programs can be made via credit card, PayPal, bank transfer, cash or check and customers will be invoiced for payment following submission of the registration form. Full payment will secure spot in our summer camps.

I will be paying for YSA with: *

Credit card payments are made online through Quickbooks (3.4% surcharge applies). Customers will be invoices following submission of the "YSA Registration Form". Checks should be made payable to "Young Scientist Academy".

required *

I agree

I agree and acknowledge that my child’s participation is not the responsibility of the Young Scientist Academy (YSA) or the Harrelson Center, its employees, officers, or agents. I affirm and agree that as parent/legal guardian, I will grant the approved supervisors, educators 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 expressly agree to assume any such risks on my behalf and that of my child. I agree to pay the one time application fee (non refundable) of $25 and that program tuition and associated fees are due before June 1, 2020. I also grant YSA permission to photograph and video my child, and publish these images on the YSA website and affiliated social media platforms.

signature of parent or guardian *

relationship to student *

date *

I agree to receiving marketing and promotional materials

YOUNG SCIENTIST ACADEMY REGISTRATION FORM:"YSA Summer Science Camp Program"

YOUNG SCIENTIST ACADEMY REGISTRATION FORM:
"YSA Summer Science Camp Program"