YSA Code Ninas Registration Form

YOUNG SCIENTIST ACADEMY CODE NIÑAS REGISTRATION FORM

Please complete the YSA Registration and Photo Consent forms below. For registration of multiple students, one form should be completed for each student. For questions please contact Dr. Rob at [email protected].

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? *

If other list school: *

YSA Fall 2021 Code Niñas Registration

Code Niñas is a free program open to all GLOW Academy students. In addition, a few spaces will be available for non-GLOW girls to register in the Code Niñas program. Note that making the selections below does not guarantee a spot for your girl. 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.

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

Code Niñas - W & Fr 4-6p Code Niñas - Waiting List

Click here to access the YSA COVID-19 Health and Safety Standard Operating Procedures.

I have read and acknowledge the YSA COVID-19 Health and Safety Standard Operating Procedures document? *

Yes

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

Allergies? *

Yes No

If yes, explain: *

Physical Handicaps? *

Yes No

If yes, explain: *

Asthma? *

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, GLOW Academy 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 2021

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

Submit