STEM E4 STUDENT APPLICATION Please enable JavaScript in your browser to complete this form.Child's Name *FirstLastDate of Birth *Sex *MaleFemaleName of School *Current Grade *Parent's/Guardian's Email *Parent's/Guardian Cell Phone Number *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency ContactsPrimary Emergency Contact *FirstLastPrimary Emergency Phone Number *Secondary Emergency Contact *FirstLastSecondary Emergency Phone Number *My child may be released with the identification: *FirstLastRelationship *Medical InformationPhysician's Name *FirstLastPhysician's Phone Number *Dentist's Name *FirstLastDentist's Phone Number *Please list any allergies (food or medical)/special health considerations: *Permissions *I authorize all medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. Furthermore, I understand that Scholars Laboratory has the right to dismiss your child with proper notice if your child presents a danger to himself/herself or others, and is a continuous disruption to the learning process.Permission for use of photo, press release, field trip approval, and completion of anonymous evaluations/surveys. I give permission for my child to go on field trips. I release Scholars Laboratory and individuals from liability in case of accident during activities, as long as normal safety procedures have been taken. I give permission for my child’s picture and/or other media containing my child’s picture for promotional uses. Ex. Newsletter/website, pamphlets, brochures, & T.V. advertisement. I also give permission for my child to complete anonymous evaluations/surveys.The parties agree that the electronic signature(s) appearing on this agreement are the same as handwritten signature(s) for the purposes of validity, enforceability and admissibility (ESIGN Act 2000).Parent/Guardian Signature *Clear SignatureWebsiteApply