Spring 19 SBRSD Girls Science Club
FOR FEMALE IDENTIFIED STUDENTS CURRENTLY IN GRADES 3, 4 and 5

Dates: Monday, April 8th - Monday, May 20th
Location: MakerSpace at Undermountain Elementary School
Time: Dismissal- 5:00pm


Please note: This form may only be used to register one child at a time.

Email address *
Applicant Info
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's Date of Birth *
Please use format: month/day/year (01/02/03)
Your answer
Grade *
Current grade.
Science Teacher *
Your answer
Has your daughter participated in a Flying Cloud Insititute program before? *
If yes, in which program(s)?
If no, how did you hear about this program?
Parent/Guardian Info
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Email Address *
For communication and enrollment confirmation.
Your answer
Mailing Address *
(P.O Box or Street Address)
Your answer
Town *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone *
Your answer
Cell Phone
Your answer
Work Phone
Your answer
During club hours, at which number would you prefer to be reached?
Your answer
Emergency Contact Information
Please include 2 emergency contacts OTHER than yourself.
#1 Emergency Contact Name *
First and Last
Your answer
#1 Relationship to Child *
Your answer
#1 Contact Phone Number *
Your answer
#2 Emergency Contact Name *
First and Last
Your answer
# 2 Relationship to Child *
Your answer
#2 Contact Phone Number *
Your answer
Medical Information
Please answer all questions below.
Does your child have asthma? *
If yes, will they be carrying a rescue inhaler?
Does your child have any allergies? *
If yes, what allergies?
Your answer
If yes, does your child carry an EpiPen?
Does your child take any medication the Flying Cloud Institute staff should be aware of? *
If yes, what medication(s)?
Your answer
Does your child have any learning disabilities / mood disorders / behavioral challenges / other special needs that Flying Cloud Institute staff should be aware of? *
If yes, please describe and list any tips for our staff.
Your answer
Permissions
Permission to Participate *
I grant permission for my child to participate in the above Flying Cloud Institute (FCI) Program. I understand that the programs will take place at my child’s school. I hereby release and hold harmless FCI, its agents, representatives, and employees from any liability which may arise in connection with my child’s participation in the Girls Science Club. I understand that by checking "I agree" below that I accept these terms.
I give permission for photos, video or artwork of or by my child to be used for promotional material by FCI. *
Registration Requirement for (New Participants only!)
Please have your daughter write a thoughtful statement (1-3 sentences) about why she wants to participate in the program. Statements can be submitted to lberkowitz@flyingcloudinstitute.org or by mail.
***This requirement is waived if your daughter has participated in a previous Girls Science Club***

I understand that If my daughter's statement is not received by the registration deadline, it will jeopardize her acceptance in the program. *
Pick-up Policy
-Please arrive in the front lobby of the school at which the club is taking place BEFORE the end of club to streamline the pickup process.
-Club members will be escorted to the lobby by our mentors, where you will sign out your child from our program.
-We will not release your child to anyone besides those people listed on your registration form without express permission.
-If you are more than 15 minutes late for pickup, for any reason, you will be charged a fine of $10 fine for every additional 15 minutes (or portion thereof) to cover the overtime for our staff/mentors. (This fine must be paid at the time of pick-up by cash or check.)
-If you are running late for pickup, please leave a message or text for Lindsey at 413-446-9761, as the school office will be closed.
-If you will need to pick up your child early, please inform us 24 hours in advance by emailing lberkowitz@flyingcloudinstitute.org or calling the Flying Cloud office at 413-645-3058
I have read and understand the Pick-up Policy for the Girls Science Club. *
Pick-up Authorization
Please list ALL persons who are allowed to sign your daughter out from the clubs INCLUDING yourself and your emergency contacts. *
Please include first name, last name, and relationship to your daughter.
Your answer
I authorize that the above individuals are allowed to sign my daughter out from the club. *
I authorize that my daughter is allowed to walk home by herself.
Payment
Suggested donation of $80 per child

Donation can be made by using the following link:

flyingcloudinstitute.org/get-involved/make-a-donation/

Or mailed to our office using the address below:

Flying Cloud Institute
St James Place
352 Main Street, Suite 212
Great Barrington, Ma 01230

A copy of your responses will be emailed to the address you provided.
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