SciTech2U Program Registration

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Parent Email address *

Parent's Name (First and Last)

Student 1 Name (First and Last) *

Student 2 Name (First and Last)

Student 3 Name (First and Last)

Student 1 Birthdate *

YYYY

Student 2 Birthdate

YYYY

Student 3 Birthdate

YYYY

Age of Student 1 *

Age Student 2

Age Student 3

Grade of Student 1

Grade of Student 2

Grade of Student 3

Name of School Student 1

Name of School Student 2

Name of School Student 3

Gender of Child 1 *

Male

Female

Prefer not to say

Other

Gender of Child 2

Male

Female

Prefer not to say

Other

Clear selection

Gender of Child 3

Male

Female

Prefer not to say

Clear selection

Street Address *

City and State *

Zip code *

County *

Telephone Number *

County or Ward (DC only)

Race *

Asian

Black

Latino

Native American

White

Prefer not to say

Middle Eastern/Arab

Other:

Household Income *

$0-$49,000

$50,000-$74,999

$75,000-$99,999

$100,000-124,999

$125,000-$149,999

$150,000-$174,999

$175,000-199,999

$200,000+

Prefer not to sa

Other:

How many people live in your household *

Prefer not to say

Other:

Please select from program below.

Techbridge

First Robotics (8 students max)

Technovation

STEM Wellness (Washington Grove elementary School only)

Teen Science Cafe

Math Tutoring Mondays and Fridays (Support K-12 Math Courses) $55/month

English Language Arts Tutoring

Summer Camp

Everything Engineering (Gaithersburg Middle Only)

Afterschool STEM (Tuesdays)

Other:

Clear selection

Emergency Contact (Name)

Emergency Contact Phone

Pediatrician's Name

Pediatrician's Phone number

Hospital of Preference

Referred by

Students participating in SciTech2U will be provided with the proper lab safety training. SciTech2U will take all preventative measures to ensure that all students are working and learning in a safe environment. Basic first aid measures will be provided by SciTech2U in case of minor injuries/accidents in face-to-face programs. By writing my name below I (parent/guardian) agree to enroll my son/daughter/custodial child in SciTech2U 's program and hereby release SciTech2U from any claims, actions, suits, costs, expenses, damages or liabilities, including attorney's fees for personal injury, property damage, accidents, illnesses, death, or any incidental damages that may arise from my child's use of the facilities or equipment or from participation in the activities or receipt of instruction. The student agrees—writing his/her name below—to abide by all laboratory and classroom safety rules and regulations that will be provided. Rules and regulations are developed to prevent minor and major injuries and accidents. *

By writing my name below I understand and agree that pictures and videos of my child(ren) may be taken to promote SciTech2U Inc. on social media, posters and flyers. I further understand that I will receive no money or remuneration of any kind from SciTech2U related to this consent and release, or the materials covered by this consent of release. I acknowledge that I do not have the right to inspect or approve any materials developed by SciTech2U, Inc. as authorized below. This release and consent includes the right of SciTech2U Inc. to: 1. Make and copyright text, photographs, audio and/or video recording of my child’s/children’s image and voice a part of SciTech2U Inc. program, and 2. use, produce, distribute and disseminate such materials and projects in any form, manner, or mode of electronic transmission for related purposes. I hereby certify and represent that I am over 18 years of age and have read the foregoing and fully understand the meaning and effect thereof. In the case of a child under the age of 18, I state that I am the parent, guardian, or otherwise legally authorized adult capable of giving consent on behalf of the minor child. Please note SciTech2U will make its best effort to ask the youth if they would like their picture taken. *

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