STEM AFTER SCHOOL PROGRAM
Student-Powered Experiments
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
School/Grade
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Any Allergies or Medical Conditions?
Yes
No
Please give details
Please tell us your child's favorite subject.
Please tell us your child's least favorite subject/toturing target area.
Please upload a profile picture of the child
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I, undersigned, agree with the following statements:
I am the parent/guardian of the child indicated above.
If an emergency occurs and I am unavailable, I authorize the supervising adult to contact emergancy persons for my child.
I am giving my permission to take my child's pictures for classroom projects and post them on the Master Minds website.
I am willing and able to pay $60 weekly to maintain my child's enrollment at Master Minds Tutoring.
Date
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Month
-
Day
Year
Date
Signature
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