Innovate & Discover Enrichment Program Registration Form

STEMology Academy by Y.E.B.S presents..
"Innovate & Discover"

Summer Enrichment Program
Location*
Enrollment Selection*
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
School Child Attends*
Upcoming Grade*
Use "0" for K-5
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Is the student required to take any meds/inhalers etc during camp hours? If yes, please explain any instructions.*
Would you prefer your child to participate in swimming lessons if offered?
**I understand my Camper is expected to adhere to all Your Essential Business Source/STEMology Academy (Innovate & Discover Enrichment Program) safety guidelines, rules, and expectations.**

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by STEMology Academy, Y.E.B.S,. In exchange for the acceptance of said child’s candidacy for STEMology Academy, Y.E.B.S., I assume all risks and hazards incidental to the conduct of the activities, and release, absolve and hold harmless STEMology Academy, Your Essential Business Source and all its respective officers, agents, and representatives from any and all liability for injuries to the said child. In case of injury to said child, I hereby waive all claims against STEMology Academy and Your Essential Business Source including all mentors and affiliates, all participants, and sponsoring agencies.

Medical Release and Authorization As Parent and/or Guardian of the named Camper, The Participant’s medical conditions and information stated on this registration are complete and correct. I give permission to the staff to (1) provide appropriate first aid for minor injuries; and (2) seek further medical treatment from local physicians or hospitals if the medical condition warrants.
Informed Consent and Acknowledgment/Medical Release and Authorization*

Clear
Media Release Your child may be photographed, videotaped,
audio recorded, and/or interviewed; and may be featured in materials for print, web, video, and social media use (known as Media Coverage.)
Media Release Agreement*
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Would you be interested in participating in an afterschool program/holiday/teacher workday camp for Fall 24-25 school year?

My Products*

Non-Refundable Registration Fee

7 Weeks of Summer Enrichment 9:00a-3p, Breakfast, Lunch, Snack, Local Field Trips

$250.00

	Age Group	Age
5-9 Year Old Explorers
10-12 Year Old Adventurers
13-15 Year Old Trailblazers

Item subtotal:$0.00

Before/Aftercare Weekly Fee (The $60 fee can be paid on the first day of camp but must be selected during registration to secure a spot if needed)

8a-9:00a and 3p-5:30p

$ Free QuantityAge
Item subtotal:$0.00

T-Shirt

$12.00 QuantitySize
Item subtotal:$0.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

Youth SYouth MYouth LAdult SAdult MAdult LOther
Should be Empty:

STEMology Academy by Y.E.B.S presents..

"Innovate & Discover"

Credit Card