STARBASE Homeschool Registration 2024-2025

STARBASE Homeschool Registration
Location

Maxwell AFB Bldg 835 (Basement)
Permission Form and Emergency Health Form

STARBASE
Student's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Age
Ethnicity

HispanicNon-Hispanic
Race

American Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific IslanderBlack or African AmericanWhiteMore than one Race
Military Affiliation: Includes children of Active Duty, Guard, Reserve, and retired members of the Armed Force

YesNo
ESL/ELL: English as second language

YesNo
Title 1 Eligible

YesNo
504/IEP

YesNo
NOTE: DoD STARBASE is required to collect demographic data on all student participants. The data is used in aggregate form ONLY to compile participant statistics for the DoD STARBASE annual report.
Parent/Guardian Information
Name*

First NameLast Name
Home Number*
Cell Number
E-mail*
example@example.com
Emergency Contact (other than Parent/Guardian information)
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
Alt. Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the student prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by STARBASE. In exchange for the acceptance of said child’s candidacy by STARBASE., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless STARBASE and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against STARBASE . including all instructors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all science experiments and activities.
Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
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.
Date

MonthDayYear
Date
Signature*

Powered by Jotform SignClear

Permission for Publication of Student Photo

Student Photo Release Form
While your children are at STARBASE Maxwell, we have great photo opportunities when they are working on projects, during hands-on and outdoor activities. We would like your permission to use photographs taken during class time to post internally in classrooms, hallways, for teacher education and /or as a historical record.

STARBASE Maxwell also uses photographs of children for publicity purposes. We promote our program using color brochures, our website, and other types of promotional materials. When photographs are used for publicity purposes, the children are never identified by name.
Please indicate your preference and sign below.

YES, I grant permission for my child's image/photograph to be used as described above.NO, I do not grant permission for my child's image/photograph to be used as described above.

Base Pass Information
Only complete form if you require base access for the duration of the STARBASE session. We must have 2 people authorized to drop off and pick up student. No additional passes will be given during week of camp.
The requested Base Pass Information is a requirement from the Maxwell Air Force Base Security Forces and the Maxwell AFB Visitor's Center. This is not a STARBASE Maxwell requirement. The information that you provide will only be used to secure your access to Maxwell AFB during you designated visit. There are internal security measures that are in place to insure that your pertinent information is handled properly and secured while in our care.
Full Name

First NameLast Name
Date of Birth
Drivers License #
State:
Full Name

First NameLast Name
Date of Birth
Drivers License #
State:
Should be Empty:

STARBASE Homeschool Registration

Location

Permission Form and Emergency Health Form

NOTE: DoD STARBASE is required to collect demographic data on all student participants. The data is used in aggregate form ONLY to compile participant statistics for the DoD STARBASE annual report.

Permission for Publication of Student Photo

Base Pass Information