Fall 2024 STEAM School Co-op Registration

Fall 2024 STEAM School Co-op Registration
Parent(s)*

First NameLast Name
First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Cell)*

Area CodePhone Number
Phone Number (Home)

Area CodePhone Number
Phone number (Alternate)

Area CodePhone Number
Email*
example@example.com
Secondary Email
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Who has permission to pick up your child?*
Is there anyone who DOES NOT have permission?*
Please see our website for our updated parent packet, schedule and fees
Which 20234 fall semester option would you like to register your child(ren) for? Please choose all applicable days.*

MONDAYWEDNESDAY (Middle/High School)THURSDAYNature School(Wednesday)
Student Information
Student 1*

First NameLast Name
Birthday
Grade
What would you like us to know about your child?(Special needs, any diagnosis, best teaching practices, interests, etc.)
Student 2

First NameLast Name
Birthday
Grade
What would you like is to know about your child? (Special needs, any diagnosis, best teaching practices, interests, etc.)
Student 3

First NameLast Name
Birthday
Grade
What would you like is to know about your child? (Special needs, any diagnosis, best teaching practices, interests, etc.)
Student 4

First NameLast Name
Grade
Birthday
What would you like us to know about your child? (Special needs, any diagnosis, best teaching practices, interests, etc.)
Student 5

First NameLast Name
Grade
Birthday
What would you like us to know about your child? (Special needs, any diagnosis, best teaching practices, interests, etc.)
In order to help STEAM staff with planning, please check ALL that apply

I am interested in learning more about being a Lead Teacher (Lead teachers are exempt from drop off fees)I am interested in learning more about being an Assistant Teacher (Assistant teachers are exempt from drop off fees)I have a child who is 4 years old or younger that would need nursery care during the day if I am selected for a lead or assistant teaching position
Fee Agreement
I will be dropping off one or more children on Mondays, Tuesdays, Wednesdays or Thursdays. My monthly drop off fees will be... (see parent packet to determine your drop off fees per number of children being dropped off)
I understand that I must pay the $100 annual registration fee in order to secure enrollment. If my child/children placement cannot be fulfilled then this fee will be used to place us on the waitlist. Once enrolled, I must pay the $200 family fee prior to the start of the fall semester. Applicable drop off fees are due monthly. Summer camp fees will be due with confirmation of registration.

Once my registration has been confirmed, payment can be mailed by check to The STEAM School at P.O. Box 112, Markham, VA 22643 or via QuickBooks. Once registered, I will recieve an invoice via email. I understand that these fees are non-refundable execpt in the case to be removed from the waitlist.
I agree to this by typing my name below. *

Photo Release
Type a question*

I grant to the STEAM school, its representatives and volunteers the right to take photographs of me and my children during STEAM co-op time or STEAM events. I authorize the STEAM school to use and publish the photos in print and/or electronically.I do not grant permission for photos to be taken of my child.I grant permission for photos to be taken of my child for use in our community groups only.Other
If OTHER: I grant permission for my child to be used in publication under the following conditions...
I agree to this photo release by typing my name:*

Medical release
For Drop off parents only: I designate the following person to serve as a parent proxy in my absence, (Either a friend, or our coordinators, Beth Herz and Tamara Fickling)
By signing this form, I hereby waive the STEAM School, its officers and members, from any liability of injury and loss or damage of personal property associated with participating in this event. I understand that my children are under the care of a parent proxy, not the STEAM School. By typing my name below, I acknowledge that I understand this waiver.
Name and date*
Medical Information
Pediatrician
Phone Number

Area CodePhone Number
Allergies or other medical conditions
Insurance Information (name, provider, group#, policy#)
Should be Empty:

Fall 2024 STEAM School Co-op Registration

Student Information

Fee Agreement

Photo Release

Medical release

Medical Information