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Fall 2018 Lee Girls Science Club

Dates: Tuesday October 23rd- Tuesday December, 18th
Location: Lee Middle and High School
Time: Dismissal- 5:00pm

Please note: This form may only be used to register one child at a time.

Email address *
Applicant Info
Daughter's First Name *
Your answer
Daughter's Last Name *
Your answer
Daughter's Date of Birth *
Please use format: month/day/year (01/02/03)
Your answer
Grade *
Current grade.
Science Teacher *
Your answer
Has your daughter participated in a Flying Cloud Insititute program before? *
If yes, in which program(s)?
If no, how did you hear about this program? *
Parent/Guardian Info
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Email Address *
For communication and enrollment confirmation.
Your answer
Mailing Address *
(P.O Box or Street Address)
Your answer
Town *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone *
Your answer
Cell Phone
Your answer
Work Phone
Your answer
During club hours, at which number would you prefer to be reached?
Your answer
Emergency Contact Information
Please include 2 emergency contacts OTHER than yourself.
#1 Emergency Contact Name *
First and Last
Your answer
#1 Relationship to Child *
Your answer
#1 Contact Phone Number *
Your answer
#2 Emergency Contact Name *
First and Last
Your answer
# 2 Relationship to Child *
Your answer
#2 Contact Phone Number *
Your answer
Medical Information
Please answer all questions below.
Does your child have asthma? *
If yes, will they be carrying a rescue inhaler?
Does your child have any allergies? *
If yes, what allergies?
Your answer
If yes, does your child carry an EpiPen?
Does your child take any medication the Flying Cloud Institute staff should be aware of? *
If yes, what medication(s)?
Your answer
Does your child have any learning disabilities / mood disorders / behavioral challenges / other special needs that Flying Cloud Institute staff should be aware of? *
If yes, please describe and list any tips for our staff.
Your answer
Permission to Participate *
I grant permission for my child to participate in the above Flying Cloud Institute (FCI) Program. I understand that the programs will take place at my child’s school. I hereby release and hold harmless FCI, its agents, representatives, and employees from any liability which may arise in connection with my child’s participation in the Girls Science Club. I understand that by checking "I agree" below that I accept these terms.
I give permission for photos, video or artwork of or by my child to be used for promotional material by FCI. *
Registration Requirement for (New Participants only!)
Please have your daughter write a thoughtful statement (1-3 sentences) about why she wants to participate in the program. Statements can be submitted to or by mail.
***This requirement is waived if your daughter has participated in a previous GIRLS Science Club***

I understand that If my daughter's statement is not received by the registration deadline, it will jeopardize her acceptance in the program. *
Pick-up Policy
-Please arrive in the front lobby of the school at which the club is taking place BEFORE the end of club to streamline the pickup process.
-Club members will be escorted to the lobby by our mentors, where you will sign out your child from our program.
-We will not release your child to anyone besides those people listed on your registration form without expressed permission.
-If you are more than 15 minutes late for pickup, for any reason, you will be charged a fine of $10 fine for every additional 15 minutes (or portion thereof) to cover the overtime for our staff/mentors. (This fine must be paid at the time of pick-up by cash or check.)
-If you are running late for pickup, please leave a message or text for Lindsey at 413-446-9761, as the school office will be closed.
-If you will need to pick up your child early, please inform us 24 hours in advance by emailing or calling the Flying Cloud office at 413-645-3058
I have read and understand the Pick-up Policy for the GIRLS! Science Club. *
Pick-up Authorization
Please list ALL persons who are allowed to sign your daughter out from the clubs INCLUDING yourself and your emergency contacts. *
Please include first name, last name, and relationship to your daughter.
Your answer
I authorize that the above individuals are allowed to sign my daughter out from the club. *
I authorize that my daughter is allowed to walk home by herself.
This program is free for all applicants.

If you are in the financial position to do so, we appreciate donations. Donation money will be used directly towards the stipend we provide for the teenage mentors, who dedicate a significant amount of time to work with your children. Check donations can be made payable to Flying Cloud Institute and remit to:

Flying Cloud Institute
St James Place
352 Main St. Suite 212
Great Barrington, Ma 01230

A copy of your responses will be emailed to the address you provided.
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