STARBASE Kingsley - Cohort 1: Keno- Application Form
Mondays: 10/19, 10/26, 11/2, 11/9, 11/16  
9 AM - 2 PM
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Email *
Student First Name *
Student Last Name *
Parent / Legal Guardian (First and Last Name) *
Parent / Legal Guardian Cell# *
Preferred Contact Method *
Participation in STARBASE classes is on a first come, first served basis. The first 8 complete applications for each cohort will receive an acceptance email/call with final attendance information. Completion of this form does not guarantee a seat in class. *
This is a cohort 1 application form for class on the following dates: Mondays 10/19, 10/26, 11/2, 11/9, 11/16. Please confirm that these are the dates you wish to apply for. If you would prefer to apply for a different cohort, please go back to the class schedule page. *
Destination *
Transportation: Parents / Legal Guardians will be responsible for driving their children to and from STARBASE on each scheduled day of class. Class will begin promptly at 9 AM and end at 2 PM. *
Medical Information: Please include any known  allergies or other information you would like STARBASE staff to be aware of.
Please be aware that STARBASE sites are not permitted to administer medication of any kind to students. STARBASE facilities do not have an onsite school nurse. *
Special needs: Please list any special needs requirements you would like STARBASE teachers to be aware of (Example: My child has a learning disorder and will need extra time or assistance with reading activities)
Person to contact in case of emergency:   *
Emergency Contact Telephone:   *
Permission is granted for my child to participate in STARBASE  S.T.E.M. activities, knowing that for each of the 5 days, my child will be asked to wear a protective mask that covers the nose and mouth, bring a water bottle, lunch and Socially Distance according to current State Mandates.  I will not bring my child if she/he has knowingly been exposed to Covid 19 or is showing symptoms of Covid 19.  I understand that, due to Covid 19 health restrictions, no parents will be allowed in the STARBASE Building. *
I will take full responsibility for any damage that might occur to government/STARBASE property caused by my child.  Should such participation result in injury or illness, I agree not to hold the US Government, National Guard and State of Oregon, its employees, STARBASE personnel or agents liable in any way.  I also understand that STARBASE reserves the right to terminate the participation of my child if it is deemed to be in the best interest of either the child, or academy, as determined by the STARBASE staff. *
In case of emergency, I authorize STARBASE Oregon staff to obtain emergency medical care for my child or ward if they deem necessary.  I agree the cost of such medical care is my responsibility *
Photo Release Permission Form: STARBASE Oregon would like to include your child’s picture and/or schoolwork in future media publications or on our website. Students will NOT be referred to by name, just by STARBASE academy and date. (Example – STARBASE Portland student in October, 2020.) *
Dress Code: Students should dress appropriately for outdoor activities on each day of class. *
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