Apply For STEM E4 – Scholars Lab

STEM E4 STUDENT APPLICATION

Child's Name *

First

Last

Date of Birth *

Sex *

Name of School *

Current Grade *

Parent's/Guardian's Email *

Parent's/Guardian Cell Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Emergency Contact *

First

Last

Primary Emergency Phone Number *

Secondary Emergency Contact *

First

Last

Secondary Emergency Phone Number *

My child may be released with the identification: *

First

Last

Relationship *

Physician's Name *

First

Last

Physician's Phone Number *

Dentist's Name *

First

Last

Dentist'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 *

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