New Scientist Registration Form

Student Details:

Student #1 Full Name*

First NameLast Name

Student #1 Date of Birth

MM/DD/YY

Student #2 Full Name

First NameLast Name

Student #2 Date of Birth

MM/DD/YY

Student #3 Name

First NameLast Name

Student #3 Date of Birth

MM/DD/YY

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail

example@example.com

Which Program are you registering for?*

Tuesdays Lower Elementary (5-7yo) at 9:30AM in DavieWednesdays Lower Elementary (5-7yo) at 1:00 PM in North LauderdaleWednesdays Upper Elementary (8-10 yo) at 11:30 AM in North LauderdaleThursdays Upper Elementary (8-10 yo) at 11AM in North Lauderdale

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

I, on my own and my child's behalf (and all respective successors), forever release Eye of a Scientist, LLC, and all members of said company from any and all liability and damages associated with any injuries incurred while my child/children are under the instruction, supervision, or control within the setting 3900 SW 100th ave, Davie, FL 33328. If any disagreement(s) are to be settled in a court of law, I will be responsible for any and all attorney fees, court fees, and any other legal fees that may arise on our own behalf as well as associated with my disagreements. I agree that I have read the above policies and fully understand them. I have read and understand the acknowledgment of risk and waiver of liability and I volunteer to affix my name in agreement and of the policies and regulations stated therein. I/We give permission for a licensed doctor or physician to administer any necessary medical attention immediately to our child(ren), and to do so without having to wait until I/we are contacted. Please type the students name, your name and date. Signing your name below will confirm your agreement with the above statement and will serve as an ELECTRONIC SIGNATURE.

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 registrationNo, please send payment linkOther

Photo Release, Please sign the this form to give your permission for your child(ren) to have their photo taken during a class scheduled with Eye of a Scientist, LLC. We may occasionally take photos for the following reasons: - to display on our Community and private class Facebook/Instagram social media page- to keep you up to date on our lesson activities- to use for lesson display- to show your student(s)' work on our community blog and Facebook/Instagram social media page- for student homeschool portfolios. Eye of a Scientist, LLC. may use photos of my child(ren) for the following uses:*

For any use listed above in the descriptionFor family use ONLYOther

Parent/Guardian Signature*

How did you hear about us?*

Please Specify*

Please give reference of any two people whom you feel would like to learn about the program:

	Full Name	Email	Contact Number
1
2

New Scientist Registration Form

Program Forms and Policies