The STEM Foundation
Registration Form
Parent / Guardian Name:
_________________________________________________________
Parent / Guardian Email:
_________________________________________________________
Parent / Guardian Phone:
_________________________________________________________
Address:
_________________________________________________________ _________________________________________________________ _________________________________________________________
Student Name:
_____________________________________________
Student Date of Birth: MM / DD / YYYY
____________________________
Student School / Home School:
_____________________________________________
Student Grade Level:
___________
Emergency Information - List contact information
(Name and cell#)
Mother Name: Cell#
Father Name: Cell#
Guardian Name: Cell#
Release Form*
By sending this form back, the Parent / Guardian acknowledges South Union CDC / The STEM Foundation are not liable for any injuries or loss of personal property. Parent / Guardian agrees to defend, indemnify and hold South Union CDC and The STEM Foundation and any and all of its volunteers, employees and contractors harmless from any claim arising from any injuries or damage caused to any person and/or property. Parent / Guardian understands and gives consent (in the event they are unavailable and there is an emergency) to transport enrolled student to any hospital, medical facility, and/or allow medical professionals to administer whatever emergency medical care is deemed appropriate by the emergency medical staff, until such time as Parent / Guardian can be contacted. Parent / Guardian understands that South Union CDC and The STEM Foundation will make every effort to notify Parent / Guardian in the event that medical attention is required for student attending the classes.
Registration Policy:
By clicking the Submit button, the Parent / Guardian agrees with following Registration Policies of The STEM Foundation program. Our program is free, but you must register your child to participate in our programming. Registrations are taken on a first come, first serve basis starting today and we can only accept 60 students. Contact us at: efrembjernigan@gmail.com, if you should have questions.
"Our program operates from 9am - 1pm".
"WE WOULD RATHER YOU STAY AT THE PROGRAM WITH YOUR CHILD / CHILDREN."
*** If you leave and come back after 1:15pm ***,
you will be charged a Late Pick Up Fee as follows:
First Time: $5.00 per each 5 minutes late per child.
Second Time: $10 per each 5 minutes late per child.
Third and Subsequent Times: $15 per each 5 minutes late per child
(***Payment due upon arrival***)
Please go to the following link, if you can't cut & paste this document:
http://www.123formbuilder.com/form-4838574/membership-application-form
http://www.123formbuilder.com/form-4838574/membership-application-form