She Can STEM Academy Participation Form
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Student Full Name* *
Date of Birth *
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/
DD
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Phone Number
Student Email Address
Social Media Names *
Please provide social media name for Instagram, Facebook and any other social media platform that you use regularly.
Race/Ethnicity
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Current School *
Current Grade/Year *
Have you participated in She Can STEM Academy workshops in the past? *
Required
How did you hear about She Can STEM Academy *
Parent/Guardian Name
Parent/Guardian Phone Number
Parent/Guardian Email
Emergency Contact Name
Emergency Contact Phone Numer
Relationship to participant
List any allergies or special needs
Release of Information: I hereby release and hold harmless Butterfly Village Incorporated, its officers, employees, agents, representatives, volunteers, heirs, executors, and assigns from all liability for personal injury, including death, as well as all property damage or loss arising out of my/my child’s participation in She Can Academy STEMand any travel/transportation-related to this program, whether paid for by myself or by Butterfly VillageIncorporated. I understand that this release and indemnification release liability for the conduct of ButterflyVillage Incorporated and its officers, employees, agents, representatives, volunteers, heirs, executors, and assigns.
Please type full name to agree to release of information statement
Photo Release: The undersigned gives permission to Butterfly Village Incorporated to use photographs and audio and/or video recordings of She Can Academy STEM for fundraising and/or marketing purposes. On occasion, with permission, Participant photographs may be included in promotional videos, websites, newsletters. ButterflyVillage respects the privacy of its participants and does not allow unauthorized visitors to photograph or video the camp or its Participants.
Please type full name to agree to photo release statement
Participation Consent: The undersigned consents to participate in any and all activities, including transportation (if applicable) to and from She Can Academy STEM activities, except those specifically prohibited by the participant’s physician.
Please type parent/guardian full name for participation consent
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