Unlimited Hands-On Science After School Program Registration Form

School Name*

Jr. Specialist #1*

First NameLast Name

What is Jr. Specialist #1's Age?*

Jr. Specialist # 1 Grade*

Jr. Specialist #1 Homeroom Teacher's Name*

Please List Any Conditions or Allergies That Would Affect Your Child's Participation (Jr. Specialist #1)*

Jr. Specialist #2

First NameLast Name

What is Jr. Specialist #2's Age?

Jr. Specialist #2's Grade

Jr. Specialist #2 School and Homeroom Teacher's Name

Please List Any Conditions or Allergies That Would Affect Your Child's Participation (Jr. Specialist #2)

Parent's Name*

First NameLast Name

Home Phone*

Work Phone

Emergency Contact (Include Names and Numbers)*

Cell Phone*

E-mail*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Registration Packet (located on menu bar of home page.)*

Yes, I have completed the 2019-2020 Registration packet. (Can be emailed or returned to physical location.)

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Unlimited Hands-On Science Pre-Registration