SCIENCE ENCOUNTERS REGISTRATION
(FALL SESSION)

Please fill out the form below and click 'Continue'. Red indicates required fields.

School:

Homeroom Teacher's Name
(Only required for afterschool programs):

Participant:

Birthdate:

Age:

Grade:

Any medical conditions/allergies?
If yes, please explain.

 Yes No

Parent's/Guardian Name(s):

Address:

City:

State:

Zip:

Home Phone:

Cell Phone/Work Phone #1:
Name:

Cell Phone/Work Phone #2:
Name:

Emergency Phone Number:
Name:

Email:

After class, student will...

 Be Picked-Up Go to Columbia Association aftercare program N/A

Authorized person to pick-up participant:
Phone Number:

Comments:



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