Make125 Home Schooler Profile

Home School Student Registration: Make125 STEAM TEAM

Home School Sessions for 3rd-5th Grade STEAM TEAM THURSDAYS February 7th - March 14th (Closed on February 19th-20th)
This form collects information about Home School Students at Greenbelt MakerSpace. Please complete one form for each participant. Upon receipt we will confirm your reserved seat(s). You may, of course, pay in person at the MakerSpace but your reservation is not complete until payment is received. Questions? Email susan@make125.org.
Student's Name *

First Name Last Name
Student Grade *

Third (3rd) Fourth (4th) Fifth (5th)
Contact and Release Information
Parent or Legal Guardian Name *

First Name Last Name
Your Name (if different from above)

First Name Last Name
Email *
example@example.com
Phone Number *

- Area Code Phone Number
2nd Email
example@example.com
Please Note: We can not release a child to leave without your explicit instructions.
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *

- Area Code Phone Number
Additional Emergency Contacts and Related Information
Please supply any additional information that might be relevant.
Medical Information
Does the student have any allergies? *

Yes No
Does the student have seizures? *

Yes No
Does the student require special health care? *

Yes No
Does the student have a developmental disorder or intellectual disability? *

Yes No
Does the student have limits on physical activities? *

Yes No
Does the student take any medication? *

Yes No
Note that MakerSpace volunteers are not authorized to supply or administer any type of medication, including over the counter drugs.
Please provide detailed information about any of the above
Please supply any additional information that might be relevant.
Greenbelt MakerSpace Policies
MakerSpace Membership

Membership in the Greenbelt MakerSpace Cooperative is required ($20 annual fee per adult), and participation in camp by household Associate Members is subject to certain policies. Members are expected to act with care and responsibility to enhance an educational environment. If the Member's behavior is not acceptable for a school room, it will not be acceptable at the MakerSpace. Membership may be denied or canceled at the sole discretion of the MakerSpace management. Any unused tuition or fees will be refunded.
I acknowledge that membership in the MakerSpace is required for this activity. *

Yes No
Waiver of Liability

In consideration for the Greenbelt MakerSpace allowing the Associate Member to participate in educational classes and other activities, you agree that you assume all risk of such participation. You agree that you release the MakerSpace and all of the MakerSpace's directors, officers, employees, volunteers, sponsors, and agents from all claims for any injury of any kind or other damages that may occur because of the member's participation. However, you do not release any claims against any individual person who intentionally causes injury.
I acknowledge and accept the MakerSpace policy on liability. *

Yes No
Requested Consent of Image and Video Recording

The Greenbelt MakerSpace desires to use images and/or videos of participants in activities to record and promote the mission of the MakerSpace. You consent to allow the MakerSpace to use images/videos in social media, press releases, and other promotional materials. The MakerSpace will make every effort to keep all personal information private. The MakerSpace complies with the Children’s Online Privacy Protection Act (COPPA) of 1998, revised in 2012. More information about COPPA is online at http://make125.org/info/privacy.
I acknowledge and accept the MakerSpace policy on media publicity. *

Yes No
Home School Student Fees

Home School Student Attendee Make 125 Steam Team February 7-March 14, 2019) $ 250.00

Total $ 0.00
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Home School Student Registration: Make125 STEAM TEAM

Contact and Release Information

Medical Information

Greenbelt MakerSpace Policies

MakerSpace Membership

Waiver of Liability

Requested Consent of Image and Video Recording