Registration for After School Universe Program
Use this form to register your middle school child for the Story of the Stars:Modeling the Universe Program beginning August 30, 2018. Payment should be completed as soon as possible to keep your spot. Online payments will not be processed/"shipped" unless a spot is available. Do not pay at SPI without contacting Rachel first.
Email address *
Child's Last Name *
Your answer
Child's First Name *
Your answer
Child's birthdate (Make sure birth year is correct) *
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DD
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YYYY
Child is currently in grade: (your child must be old enough to attend public school sixth grade to attend this program) *
Your answer
Gender (so that we address your child with appropriate pronouns)
Your answer
Caregiver Full Name/s *
Your answer
Medical or other information we should know about your child. Please make sure to note any special needs (diagnosed or not) that will help this program work for all children who attend. *
Your answer
We are required to document this program for the grant. This will include taking pictures and possibly videos, and you may be required to sign an official NASA photo release. We do publish pictures on Facebook, but do NOT identify by name any child. It is difficult for us to exclude a particular child. *
Required
Emergency Contact#1 information: Please include name, relationship to child, working phone number/s. The First Emergency Contact is usually the same as the Caregiver listed above, but it must be somebody who can be called during the program after school. *
Your answer
Emergency Contact #2 information: Please include name, relationship to child, working phone number/s.
Your answer
In the event I cannot be reached in an emergency, I hereby give permission to a physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, or to order injection or surgery for my child. *
Required
Mailing Address *
Your answer
Payment: Cost is $75 for non members, $50 for Yearly SPI members, $5 for extreme financial need *
Required
Anything else you wish to tell us.
Your answer
A copy of your responses will be emailed to the address you provided.
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