2017 Spring ~ After School Science Classes for Grades 1-5 ~
Please sign up each child individually.
- Grades 1-2 will meet on WEDNESDAY March 15 - April 26.
- Grades 3-5 will meet on THURSDAY April 10 - May 19.

Classes will be held at the Great Lakes Research Center (Room 104) from 4:00 - 5:30 pm.

Student Name *
Your answer
Your child is: *
Which school does your child attend? *
Your answer
What grade is your child? *
Your answer
Please make a selection below for children: *
Six sessions once a week at the GLRC from 4:00 - 5:30 pm.
Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian Phone Number *
Your answer
Address *
Your answer
Is this your child's first time attending a Center for Science and Environmental Outreach program through Michigan Tech? *
Person(s) authorized to pick up your child/Emergency contact *
Please list all people who may potentially pick up your child along with their phone number and relationship to the student.
Your answer
Please list any medical conditions along with medications associated with your child (bee/peanut/shellfish allergies, asthma, diabetes, etc.). *
If your child has an inhaler, epi-pen, or insulin injections, please specify.
Your answer
Does the Center for Science and Environmental Outreach and Michigan Tech have permission to use photos of your child in educational or promotional materials? *
How did you hear about our program? *
Your answer
Please read the following liability release and parental consent and type your name in the box provided below.
LIABILITY RELEASE AND PARENTAL CONSENT ~ Students (or their parents, if a minor) participating in programs offered through Michigan Tech (“the University”) and coordinated by the Michigan Tech Center for Science & Environmental Outreach (“the Center”) must sign and submit this LIABILITY RELEASE AND PARENTAL CONSENT form. Participants will engage in a variety of educational programs led by Michigan Tech faculty, staff and students, and invited community educators/specialists, that may be held at the Great Lakes Research Center, on Michigan Tech's Campus, aboard the Agassiz research vessel, at the Nara Nature Center, or at the Marsin Center, and/or on field trips. Consent, Waiver, Release and Assumption of Risk. I, the undersigned participant, or parent or guardian of a minor participant, understand that there are inherent risks associated with this activity that cannot be eliminated, and that each participant must assume the risk of injury or disabilities that could result. I hereby acknowledge that I am aware of these risks and I agree that I will, or if signing as a parent or guardian, to, follow all safety instructions and ask questions if I or they do not understand. In consideration of the acceptance of myself or the minor as a participant in the Michigan program, I assume the risk of and full responsibility for any bodily injuries, death, damages or expenses to me or the minor for whom I am signing which may occur in the course of or as a result of my or their participation. I do hereby fully and forever release and discharge, covenant not to sue and agree to indemnify and hold harmless Michigan Technological University and its Board of Control, employees, and agents from and against any and all claims, demands, damages or rights of action due to bodily injury, death, or property damage, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of my participation or the minor’s participation in the Michigan Tech program and all related activities and tours. I hereby further consent to and authorize the University, Center staff or program leader(s) to obtain whatever medical treatment and/or care is deemed necessary by such staff for the health and well-being of myself or the participant during the term of program participation, including the consent to obtain and have administered any emergency medical or surgical treatment. I have read the foregoing, explained its meaning to my child or ward if the participant is a minor, and hereby do approve and consent to the terms and conditions stated. If the participant is a minor I consent to the participation of my child in the Michigan Tech program, transportation in Michigan Tech vans, as needed, and all related activities and tours. In lieu of the signature of a Parent/Guardian, please type your name in the box provided below. Thank you.
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Michigan Technological University. Report Abuse - Terms of Service - Additional Terms