New Scientist Registration Form
Student Details:
Student #1 Full Name
*
First Name
Last Name
Student #1 Date of Birth
MM/DD/YY
Student #2 Full Name
First Name
Last Name
Student #2 Date of Birth
MM/DD/YY
Student #3 Name
First Name
Last Name
Student #3 Date of Birth
MM/DD/YY
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Which Program are you registering for?
Please Select
Tuesdays PreK/K (3-5yo) at 10AM in Davie
Tuesdays Lower Elementary (5-7yo) at 10:30AM in Davie
Wednesdays Middle School (11-14yo) at 10AM in North Lauderdale
Wednesdays Higher Elementary (8-11yo) at 11:30AM in North Lauderdale
Wednesdays Lower Elementary (5-7yo) on Thursdays at 1 PM in North Lauderdale
Thursdays Lower Elementary (5-7yo) at 10AM in North Lauderdale
Wednesdays Higher Elementary (8-11yo) at 11:00AM in North Lauderdale
*The program for students that are 5yo will depend on child's ability to withstand a 1 hour vs a 30 min class. Program for 11yos will depend on their math skills and capacity of collecting and analyzing numerical data.
Program Forms and Policies
Does your child(ren) have any allergies? If sos, please list the names and allergies below. If not, please put n/a.
*
EXTREME WEATHER OR UNEXPECTED INTERRUPTION OF LESSONS. There will be no refunds for lessons missed due to cancellation because of events outside our control such as power outages, hurricanes, etc.
*
I understand
MEDICAL CONDITIONS: It is the student's legal guardian's responsibility to inform us of any medical condition of the student that may interfere with a normal teaching process. I am an independent contractor and I am not trained to work with students with certain disabilities unless privately discussed.
*
I understand
Please list any medical, behavioral, emotional, or social conditions or factors that a student has. If none, indicate N/A.
*
IT IS THE RESPONSIBILITY OF THE PARENTS OR GUARDIAN TO BE AWARE OF THE SCHEDULE AND POSSIBLE CHANGES. Students and parents will be notified of any changes to scheduling or notices via provided E-mail. Please make certain that you are able to receive our correspondence by checking your E-mail settings.
*
I understand
COVID-19 or other communicable diseases: If a member of your family or someone your child(ren) have been in contact with someone diagnosed with COVID-19 or another disease after attending a group lesson, please notify Neymi Mignocchi immediately. Depending on the circumstances, Eye of a Scientist will decide if and how any regular meetings may be conducted or postponed.
*
I understand
SICKNESS AND ILLNESS: Please remember that germs travel very quickly within groups and ill students should remain at home. Students with fever or signs of illness on a day that Eye of a Scientist scheduled groups meet should stay at home. This includes students given a fever reducing medicine to alleviate and/or mask their symptoms as they may still be contagious. Eye of a Scientist reserves the right to ask any parent of a student(s) who is unwell to leave or stay home for the well being and health of the other group members. Students must be illness-free for at least 24 hours before attending a scheduled lesson.
*
I understand
Signature
*
REFUND POLICY: Payments made for the program will only be refunded before the start date of the program, not including the nonrefundable registration fee. Once the program has begun, full refunds will not be guaranteed, unless in special circumstances. Please type your name and date. Typing your name will confirm your agreement with the above statement and will serve as an ELECTRONIC SIGNATURE.
*
I understand
I've paid the non-refundable registration fee and program balance in full before the start of the program.
*
Yes, via website registration
No, please send payment link
Other
Photo Release
*
For any use listed above in the description
For family use ONLY
Other
Parent/Guardian Signature
*
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Feedback about us:
Will you be willing to recommend us?
Yes
No
Maybe
Please give reference of any two people whom you feel:
Full Name
Email
Contact Number
1
2
Submit
Submit
Should be Empty: