2018-2019 STEMulating Saturdays Application
Which site do you prefer to participate. Seats are limited in all sites and preference is given to families who participated at each site in 2017-2018. The curriculum and activities are identical at all sites. *
Student Last Name *
Your answer
Student First Name *
Your answer
Date of Birth *
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Student Shirt Size *
What grade will your student be entering for the 2018-2019 school year? *
Your answer
Are you willing to participate on the 1st Saturday of each month? If yes, please complete. If no, please stop and contact our staff to find another program for your student *
Parent or Guardian's Name *
Your answer
Relationship to Student *
Email address for correspondence *
Your answer
Emergency Contact #1 (Name and Phone Number) *
Your answer
Emergency Contact #2 (Name and Phone Number) *
Your answer
Emergency Contact #3 (Name and Phone Number) *
Your answer
Any accommodations needed to participate in our program? *
Your answer
Known allergies (food, medications, environments, etc.) *
Your answer
Child's Physician (name and number) *
Your answer
Past Medical History (ex: Epilepsy, Asthma, etc.) *
Your answer
Any other pertinent medical information? We are not responsible for any type of medical/ambulance costs. *
Your answer
Any medications? *
Your answer
I give The Gaskins Foundation/STEMulates the permission to transport my child to the hospital in the event of an emergency as deemed necessary by the staff of The Gaskins Foundation c/o STEMulates *
Preferred Hospital (we will try our best to accommodate) *
Your answer
Does your student have any behavioral issues of which our staff should be aware? *
If yes, explain
Your answer
I authorize The Gaskins Foundation and/or their authorized agent to release publicly my child's name, including pictures and videotape for use related specifically to their achievements. *
My student has permission to attend all of The Gaskins Foundation c/o Cincinnati STEMulates activities. We recognize that full participation in the program may require the student to be transported by bus/van to various activities. In consideration of the child’s participation in the program, we will release and hold harmless Gaskins Foundation’s Cincinnati STEMulates, Whitney Gaskins, The University of Cincinnati and all of their employees, officers, directors, agents, members, insurers, and associates, from any and all claims, of any sort, type, nature, or description, whether known or unknown, foreseen or unforeseen, which could be asserted against any of the above-listed entities or persons, and they expressly waive any and all such claims. Said release and waiver shall not apply to bar claims for intentional or willful conduct. *
By enrolling into the Gaskins Foundation, I am showing my commitment to enhancing our student's future while making it enjoyable. I have read and full understand these policies and procedures. *
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