Indigenous Youth Summer STEM Program Registration Form

Indigenous Youth Summer STEM Program Registration Form

To book for a place in the the camp, you must complete the form below accurately. To offer this opportunity to the greatest number of youth, we ask that you please only register for weeks of the program that your youth(s) can attend.
Summer Program Sessions:
prevnext( X )
Week 1 : July 8th - July 12th
$ Free Number of Registrants



Week 2: July 15th - July 19th
$ Free Number of Registrants



Week 3: July 22nd - July 26th
$ Free Number of Registrants
Parent/Guardian Name

First NameLast Name
Email Address
example@example.com
Home/Cell Phone Number
Preferred form of contact

CallTextEmailCall and Text
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information 2
Emergency Contact 2 Name

First NameLast Name
Emergency Contact 2 Phone Number
Please enter a valid phone number.
Relationship to Youth

Emergency Contact Information 3
Emergency Contact 3 Name

First NameLast Name
Emergency Contact 3 Phone Number
Relationship to Youth
For any additional adults who may be a form of contact, drop off and/or pick up for your youth, please list their First and Last Names
For security purposes, is there anyone not permitted to pick up your child?

Youth Information

This program serves youth in Grade 1 - Grade 12 during the 2024/2025 school year. Youth in grades 1 - 6 are considered Mentees, who work in small groups with similar aged youth. Youth in grades 7 - 12 are considered Peer Mentors, who will guide the Mentees during activities.
Youth's Name

First NameLast Name
Grade the youth will be entering during the 2024-2025 school year
Child's Birth Date

MonthDayYear
Child's Gender
If you desire, please list your tribal community/ies (optional - please note that this information will be shared with the program sponsor)
Does your child have allergies, medical concerns, or any additional information you would like us to know about them? Please include medications and other needs required of us to provide during program hours. If you indicate yes, please fill out an Individual Care Plan.
Does your child have an IEP or learning plan in school? If yes, how can we best support your youth during the program?
Is there anything else you would like to share about your child that will help make this experience a success? (e.g. Sasha can be shy at first but once comfortable, she will be the Bell of the Ball.)
Lunches are included with the program and are prepared by Narragansett Elder, Pearl Brown. Will your youth be participating in the lunch program?

YesNoMaybeOther
Please list any dietary restrictions and/or food allergies.
As we develop the menu, are there any meals that you would like to suggest for a potential addition to the menu?
Please indicate your child's swimming experience.

Strong swimmerAverage swimmerWeak swimmerNo swimming experience
What is your child's t-shirt size?

Are you registering a second child?

YesNo

Youth 2 Information

This program serves youth in Grade 1 - Grade 12 during the 2024/2025 school year. Youth in grades 1 - 6 are considered Mentees, who work in small groups with similar aged youth. Youth in grades 7 - 12 are considered Peer Mentors, who will guide the Mentees during activities.
Youth's Name

First NameLast Name
Grade the youth will be entering during the 2024-2025 school year
Child's Birth Date

MonthDayYear
Child's Gender
If you desire, please list your tribal community/ies (optional - please not that this information will be shared with the program sponsor)
Does your child have allergies, medical concerns, or any additional information you would like us to know about them? Please include medicatinos and other needs required of us to provide during program hours. If you indi
Does your child have an IEP or learning plan in school? If yes, how can we best support your youth during the program?
Is there anything else you would like to share about your child that will help make this experience a success? (e.g. Sasha can be shy at first but once comfortable, she will be the Bell of the Ball.)
Lunches are included with the program and are prepared by Narragansett Elder, Pearl Brown. Will your youth be participating in the lunch program?

YesNoMaybeOther
Please list any dietary restrictions and/or food allergies.
As we develop the menu, are there any meals that you would like to suggest for a potential addition to the menu?
Please indicate your child's swimming experience.

Strong swimmerAverage swimmerWeak swimmerNo swimming experience
What is your child's t-shirt size?

Are you registering a third child?

YesNo

Youth 3 Information

This program serves youth in Grade 1 - Grade 12 during the 2024/2025 school year. Youth in grades 1 - 6 are considered Mentees, who work in small groups with similar aged youth. Youth in grades 7 - 12 are considered Peer Mentors, who will guide the Mentees during activities.
Youth's Name

First NameLast Name
Grade the youth will be entering during the 2024-2025 school year
Child's Birth Date

MonthDayYear
Child's Gender
If you desire, please list your tribal community/ies (optional - please not that this information will be shared with the program sponsor)
Does your child have allergies, medical concerns, or any additional information you would like us to know about them? Please include medications and other needs required of us to provide during program hours. If you indicate yes, please fill out an Individual Care Plan.
Does your child have an IEP or learning plan in school? If yes, how can we best support your youth during the program?
Is there anything else you would like to share about your child that will help make this experience a success? (e.g. Sasha can be shy at first but once comfortable, she will be the Bell of the Ball.)
Lunches are included with the program and are prepared by Narragansett Elder, Pearl Brown. Will your youth be participating in the lunch program?

YesNoMaybeOther
Please list any dietary restrictions and/or food allergies.
As we develop the menu, are there any meals that you would like to suggest for a potential addition to the menu?
Please indicate your child's swimming experience.

Strong swimmerAverage swimmerWeak swimmerNo swimming experience
What is your child's t-shirt size?

Volunteer Opportunity for Adults
Please indicate if you would be interested in being a parent volunteer at any point during this program.

If so, the Program Manager will send you information on how to participate, your availability, and to learn if there is a skill you would like to share with the program participants.

* A background check is required for any volunteers or staff working with children during this program. This background check will be processed through Mystic Aquarium and will be at no cost.
Are you interested in volunteering during the program?

Yes, I am interestedMaybe, please contact me with additional informationNo

Required Paperwork

Information from all required paperwork is only shared with those who are responsible for the youth on a daily basis. Any paperwork is confidential and stored in a secured location.
These following forms are required for all youth prior to the first day of the program. If you have submitted valid health forms last year, please contact the Program Manager to verify. For all others, please upload your forms below or email them to the Program Manager, Nikki Saccoccia at nsaccoccia@mysticaquarium.org.

By completing this registration form, you are acknowledging that you understand that the following forms are required in order for my child/ren to participate in the program and will send them to the Program Manager prior to the start of the program.
- Updated Health form that has been completed within the last 3 years (attach here or email to Program Manager).
- Administration of Medication Form/Individual Care Plan (only required for medications administered in program)
If your forms are ready for submission, please upload here

Cancelof

Program Permissions

Please read the following carefully. Please keep in mind that the permissions we are asking for below are to ensure a safe and fun experience for all participants and to help document the success of the program for current and future funders. Without the help of our grant funders, we could not offer this opportunity to our Indigenous Youth.
Liability: I understand that during the attending camper’s participation, they may be exposed to a variety of hazards and risks, foreseen and unforeseen, which are inherent in any program, activity or field trip that involves the use of aquarium facilities or sea-related activities (collectively, a “Program”). This Program may involve, but is not limited to hiking, handling and collecting invertebrates and reptiles, field trips to various sites and habitats, wading in the water, playing games outside, and visiting non-public areas at the Aquarium. I further understand that there may not be medical facilities or professional medical personnel present during the conduct of a Program. In consideration for my acceptance as a participant in a Program provided by the Aquarium, and the services, facilities and equipment provided by the Aquarium, I confirm my understanding that:
- I have read and am familiar with the rules and conditions applicable to my participation in a Program and I understand that my participation is at the discretion of the instructor.
- The Program begins and ends at locations designated by the Aquarium, does not include carpooling or transportation to or from such locations, and that I am responsible for transportation and that I am personally responsible for all transportation risks.
- This Waiver Form is intended to be as broad and inclusive as permitted by law. If any provision or any part of any provision of this Waiver Form is held to be involved or legally unenforceable for any reason, the other provisions of this Waiver Form will not be affected and will continue to be binding.
I have read this Waiver and I freely and voluntarily assume all risks of injury to myself and/or my child that are inherent in any program, activity or field trip that involves the use of aquarium facilities or sea-related activities and freely agree to participate in the Program.
Initials for Liability Form*
Model Release: This is not a required option.
I agree and consent that Sea Research Foundation, Inc. (including Mystic Aquarium) and its nominees, project partners (Tomaquag Museum, USFWS, Southern RI Conservation District, Ocean Coalition) and assigns may use, in their sole discretion, the likeness and/or photography taken of the attending camper or any reproduction thereof, in any form, style or color, together with any writing and other advertising material, in connection therewith, including television and including, but not limited to, the use of my name and/or quotations.

This consent and release is given without limitation upon, or liability for, any use for advertising, illustration, publication, broadcast of every kind, or in trade or media, or for any purpose for promotion by Sea Research Foundation, Inc., and its nominees. I further agree that such photography and/or likeness, and the film, tape, plates, and negatives thereof, shall be and remain the exclusive property of Sea Research Foundation, Inc. I further waive any right to inspect or approve the commercial, advertising or publicity material.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS AN ADVERTISING AND PUBLICITY CONSENT AND RELEASE FORM AND I HAVE SIGNED OF MY OWN FREE WILL. This form will be accepted by agents of Sea Research Foundation, Inc. in Mystic, Connecticut, and Connecticut law shall apply to this willful advertising and publicity consent form

UNDER 18 YEARS OF AGE:

By right of legal authority invested in me, I individually and as father/mother/guardian of the above, consent to the foregoing.

Please initial one of the below options:
I agree to allow photos
I do not agree to allow photos
Program Permissions Cont.

Please read and sign to acknowledge consent
COVID-19 Information
1. Covid-19 Information: Based on current guidance, youth are allowed to select whether or not they prefer to wear a mask.
2. No field trip locations currently require a mask in order to enter.
3. Please follow current guidance on symptoms and quarantine regulations.
4. Any updates or changes will be sent to you as they arise.
Field Trips

Indigenous Youth Summer STEM program will attend field trips, host in person guests, and environmental studies. These experiences may include, but are not limited to walking or being transported by bus to local and state water way site/s, field trip locations and providers, using computers and other tech to view and engage with enrichment providers based on the safety and guidelines for COVID-19. I give permission for Mystic Aquarium and partners to walk with, or transport my child to nearby waterways and engage in in person visits and virtual enrichments. I understand that my child will be participating in water experiments and may enter the water in order to participate. I release Mystic Aquarium and its partners from responsibility for illness or injury incurred, recognizing that due care and concern will be exercised.
Sunscreen and bug spray application

I give permission for program staff to assist with reapplying sunscreen/bug spray if needed at the program. This includes staff assisting my camper in applying the sunscreen/insect repellent to the face, ears, back of neck and back while in full view of another staff member. I am responsible, as the guardian, for the initial application of sunscreen/insect repellent at the time of drop off for the day. The containers must be the original containers and have the name of the camper written on them.
Water Activity Permission

During the week(s) of your child’s participation in the program, a few of the scheduled activities will be coastal field studies, beach cleanup, and a leisure day at various beach locations. Swimming is permitted though not required, at a scheduled designated swimming area. There will be lifeguards who will be on duty and will be informed of our program's presence.

During the coastal field studies at Ninigret, swimming is not permitted. Youth will only be allowed up to their knees to explore the watershed.

We require our staff to be trained and are required to be vigilant with head counts and positioning to reduce blind spots during these activities, and the program director will also be on standby during visits. We encourage extra parent volunteers on the water days to increase the number of supervisors for safety. We ask that the volunteers not distract the staff from their supervisory activities.

By signing this, I give my child/ren permission to participate in swimming activities during their time at the program.
By Digitally Signing this I understand that my child will regularly attend the Indigenous Youth Summer STEM Program, based on the weeks selected previously, from 7/8-7/26 Monday through Friday 8am-3pm.

I also give permission for Mystic Aquarium and its funders and partners to utilize data collected from, but not limited to, pre- and post- surveys and observations. This information is used to report to Ocean Coalition, Mystic Aquarium and our other partners and funders in order to maintain our promise to provide Indigenous youth with quality programs that enhance academic and social emotional growth.

BY SIGNING, I CERTIFY THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I understand that my child/ren and family will be enrolled in the Indigenous Youth Summer STEM Program. I understand the policies and procedures and will follow them to the best of my ability.
Signature*

Powered by Jotform SignClear
Should be Empty:

Indigenous Youth Summer STEM Program Registration Form

Emergency Contact Information 2

Emergency Contact Information 3

Youth Information

Youth 2 Information

Youth 3 Information

Volunteer Opportunity for Adults

Required Paperwork

Program Permissions

Program Permissions Cont.