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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:
*
Male
Female
Genderqueer/Non-binary
I 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
*
Email
*
Emergency Medical History
This information will be kept confidential and secure on file in case of emergency.
Allergies
*
-
No
Yes
If yes, explain:
*
Physical handicaps
*
-
No
Yes
Asthma
*
-
No
Yes
If yes, explain:
*
If yes, explain:
*
Name family physician/practice
*
In case of emergency please call:
*
First
Last
family physician phone
*
Phone Number
*
type
*
-
Business
Home
Cell
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?
*
-
No
Yes
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)
Atmospheric Explorers I - $153 (July 6-10)
Atmospheric Explorers II - $153 (July 13-17)
Sea Turtle Science - $213 (July 20-24)
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:
*
No
Yes - $20 per t-shirt
Select t-shirt size:
*
-
Youth S
Youth M
Youth L
Adult S
Adult M
Adult Large
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
Check
Cash
Bank Transfer
PayPal
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
*
MM/DD/YYYY
I agree to receiving marketing and promotional materials
Submit
Home
DONATE
Code Girls
Programs
Afterschool Science Ambassadors Program (ASAP)
Youth CAUSE Initiative
Homeschool Science
Latinx Science Seminars
Virtual Experiences
About
Scholarships
Apply for a Scholarship