Super Kid Science Program Registration Form
You may visit our website and see our other programs and opportunities at
First name of participant
Last name of participant
Parent or emergency person's name
Best Contact Phone Number
Phone number(s) where I want to receive text messages. We send texts to communicate about our locations, changes and other program information.
Other emergency contact information
Medical needs and allergies we should know about.
What else do we need to know about the participant to help them have the best possible experience?
Photo Permission. Super Kid Science publishes photos in our digital albums to share our adventures, on our website and in our promotional literature and digital posts. No names are ever used in our publications.
I give consent for participant photos to be published as described above.
Please do not publish photos of this participant
Super Kid Science takes safety and well being seriously. Marilyn Jesrani is certified in first aid, CPR and as an ACA kayak instructor guide. Unfortunately, accidents and mishaps are always possible (and very likely with outdoor activities, especially minor incidents like splinters, scratches, etc..). In order to participate in our programs, you must agree that Super Kid Science, people working our programs and the owners of the locations where our programs are held can not be held liable for injury or loss of property. Any medical expenses that may occur must be paid by your family and through your personal medical insurance.
Super Kid Science is not responsible for lost, stolen or damaged property including cell phones and electronics. Always wear clothes and shoes that can get dirty to our programs.
I give Marilyn Jesrani of Super Kid Science consent to seek medical treatment for my child or this participant in an emergency.
Do you give the participant permission to participate in water activities such as boating and swimming, and if yes, what is their swimming ability?
Yes, but can not swim.
Yes, beginner swimmer
Yes, can float, hold breath under water and swim to side of pool.
Yes, can float, hold breath under water and swim at least 2 laps in a pool
Yes, Advance swimmer
For the purpose of life vests....
Participant is under 50 pounds
Participant is between 50 to 90 pounds
Participant is over 90 pounds
I allow my child to drive in a car with Marilyn Jesrani or another Super Kid Science leader that is entrusted by her. Please check all that apply.
My child must be in a car seat and I will bring the car seat to the program.
I give permission for my child to sit in the front seat
No or is not applicable to this program.
Please do not allow your child to bring toys or electronics so that they may have a full immersive experience. If you would like your child to have a cell phone as we never deny children contacting their parents, please have them store them in their back packs during the program. We can not be responsible for lost or broken items. Children should wear clothes appropriate for kayaking, hiking, getting dirty and the weather. Closed toed shoes (sneakers) are required. Children should have a backpack with sunscreen, towel bathing suit (weather dependent), and water shoes or shoes that can get wet. An emergency change of clothes is also suggested. This program is run by Super Kid Science, LLC of Holly Springs. Our web address is
. We can be contacted at 984-344-7198.
Type your full name to acknowledge that you have read and agree to all the information you entered in this form.
Check the boxes for the programs you wish to register. In order for your registration to be complete, please pay online using the "pay at ....." links. Credit cards are accepted and you do not need to have a paypal account to use these payment links. The payment links should open in a new window. Make sure you also click the submit button for this form when you are done. You will receive an email receipt with the responses from this form for your records. Check out the details for each of the programs listed below at
Pirates on Harris Lake, November 9th. Pay at
"Trailblazer Camp With Finn The Science Dog" on April 25th. Pay at
""I am a Super Hero" Save the Earth Club" for Nov 16, Dec 21 and Jan 25. (3 sessions) Pay at
"Girl Power Science Club" for Nov 16, Dec 21 and Jan 25. (3 sessions) Pay at
Robot Explorers for Nov 16, Dec 21 and Jan 25. (3 sessions) Pay at
Bath Bombs and Slime on Nov 2. Pay at
It's Rocket Science! on Nov 17. Pay at
Trailblazer Summer Camp on July 6th - 11th (six days!). To pay in full: Pay at
Trailblazer Summer Camp on July 6th - 11th (six days!) Deposit only. Pay at
Trailblazer Summer Camp on July 6th - 11th (six days!) Remaining balance. Due by June 1st if not paid in full. Pay at
Sleep with the Sharks on July 10th - 11th. Pay at
Kayak lessons and excursions. We will contact you to schedule and then email an invoice.
Private Tutoring. We will contact you to schedule and then email an invoice.
Party or Private Event. We will contact you to schedule and then email an invoice.
A copy of your responses will be emailed to the address you provided.
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