School:
If 'Other', name of school:

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

Participant:

Birthdate:

Age:

Grade:

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

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...

Authorized person to pick-up participant:
Phone Number:

Comments:

Please select the week(s) your child will be participating in:

Week 1 - Ecology Engineers | June 29 - July 3
Week 2 - Kitchen Chemistry 2 | July 6 - July 10
Week 3 - CSI: Murder Mystery | July 13 - July 17
Week 4 - Imagineering | July 20 - July 24
Week 5 - Human Body | July 27 - July 31
Week 6 - Rocketry & Flight | August 3 - August 7
Week 7 - Prehistoric Walk | August 10 - August 14
Week 8 - Veterinary Science | August 17 - August 21
Week 9 - Fizz, Bang, Pop | August 24 - August 28