STEM Clubs Application Form
I am a...
STEM Club Program Facilitator
VoS Staff Member
What is the source of this application?
Hard Copy Registration Form
When did you receive this application?
Is this application for a first-time or returning STEM Club participant?
If returning, indicate the Participant ID.
Your participant ID has been e-mailed to you. If you are unable to locate it, please contact firstname.lastname@example.org.
How many years has the participant taken part in Visions of Science programs?
How did you hear about this program? (select all that apply)
Received an E-Mail
Visions of Science Door-to-Door Visit
Visions of Science Pop-up Booth
A Community BBQ Event
Through a School
Through a Community Centre
From a Friend
What is your desired Community STEM Club Location?
Downtown - Alexandra Park (105 Grange Ct, Toronto, ON M5T 2J6)
Downtown - Bleecker (325 Bleecker St, Toronto, ON M4X 1M2)
Downtown - Coatsworth (33 Coatsworth Crescent, Toronto, ON M4C 5P9)
Downtown - Dan Leckie (150 Dan Leckie Way, Toronto, ON M5V 0E3)
Downtown - Regent Park (180 Sackville St, Toronto, ON M5A 3H1)
Downtown - Rivertowne (50 Matilda St, Toronto, ON M4M 1M4)
Etobicoke - Capri (7 Capri Road, Etobicoke Ontario)
Etobicoke - John Garland (70B John Garland Blvd.)
Etobicoke - Willowridge (44 Willowridge Rd, Etobicoke, ON M9R 3Z1)
North York - Driftwood (415 Driftwood Ave North York, ON M3N 2P8)
North York - Falstaff (30 Falstaff Avenue, Toronto ON M6L 2C8)
North York - Flemingdon Park (4 Vendome Place Unit 21A, North York, ON M3C 1E1)
North York - Lawrence Heights (5 Replin Rd, North York, ON M6A 2N3)
North York - Neptune (155 Neptune Dr, North York, ON M6A 2Y3)
North York - Pelmo (TBD)
Scarborough - Cataraqui (74 Firvalley Ct, Scarborough, ON M1L 1N9)
Scarborough - Chester Le (201 Chester Le Blvd, Scarborough, On M1W 2K7)
Scarborough - Greenbrae (55 Greenbrae Circuit, Scarborough, ON M1H 1R2)
Scarborough - Lawrence and Galloway (4110 Lawrence Ave E, Scarborough, ON M1E 2S2)
Scarborough - Mornelle (90 Mornelle Ct, Scarborough, ON M1E 4P9)
Scarborough - Victoria Park (2743 Victoria Park Ave, Scarborough, ON M1T 1A8)
York - Swansea Mews (21 Windermere Ave, Toronto, ON M6S 4V4)
York - Woolner (190 Woolner Ave, York, ON M6N 1Y3)
Brampton - Knightsbridge (150 Central Park Dr, Brampton, ON L6T 1B4)
Brampton - Queen and Kennedy (9 Ardglen Dr, Brampton, ON L6W 1V1)
Mississauga - Erincourt (1900 N Sheridan Way, Mississauga, ON L5K 2C8)
Mississauga - Malton (3540 Morning Star Dr, Mississauga, ON L4T 1Y2)
Mississauga - Peel Youth Village (121 Acorn Pl, Mississauga, ON L4Z)
Mississauga - Springfield Gardens (3590 Colonial Dr, Mississauga, ON L5L 5S1)
*Max 20 participants per club. All applications are welcome but priority is given to youth who live directly in the communities where clubs are held
Date of Birth
Grade Level (in September 2019)
Toronto District School Board
Toronto Catholic District School Board
Peel District School Board
Dufferin-Peel Catholic District School Board
Durham District School Board
York Region District School Board
Is the participant enrolled in any other program(s)?
If yes, please specify which program(s).
Race/Ethnicity of Participant (please select all that apply)
Aboriginal (First Nations, Métis, Inuit)
Black (e.g., African, Caribbean, North American)
East Asian (e.g., Korean, Japanese, Chinese)
Indo-Caribbean (e.g., Guyanese)
Middle Eastern (e.g., Iranian, Syrian, Iraqi, Lebanese)
South Asian (e.g., Indian, Pakistani, Sri Lankan)
Southeast Asian (e.g., Filipino, Vietnamese, Cambodian)
Prefer not to say
Participant Health & Safety Information
Health Card Number
Does the participant have any allergies?
If yes, please specify allergies.
Does the participant have any disabilities, exceptionalities, or require special accommodations?
Prefer not to say
If yes, please specify disabilities, exceptionalities, or special accommodations required.
Does your child carry any of the following? (check all that apply)
Does your child have any other health concerns?
If yes, please specify additional health concerns.
How will the participant be arriving/leaving the weekly program?
Will travel to and from the program on their own/with other participants
Will be dropped off and picked up from program by an authorized parent/guardian
Residence & Contact Information
Home Phone Number
What is your preferred method of communication?
Emergency Contact Information
Emergency Contact Name
Relation to Participant
Emergency Contact Number
I would like to receive parent/guardian newsletters for updates about Visions of Science events and programs
I would like to help promote this science club to my community
Consent & Liability
I hereby give Visions of Science Network for Learning consent for my child to be photographed/videotaped while attending the science club and other Visions of Science events, and to use and reproduce my child's name/image for promotional purposes. My child’s first name (unless otherwise authorized)/image may be published or used in promotional videos, program brochures, posters, electronic newsletters, on World Wide Web or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by Visions of Science Network for Learning.
I hereby give consent for my child to participate in all Visions of Science Network for Learning evaluation activities. The purpose of these activities is to identify and share the impact of the program as well as to continuously improve Visions of Science Network for Learning processes. I authorize the use of my child’s responses for evaluative and statistical purposes and understand that individual responses will be kept confidential and identifying information will never be shared with third party organizations. I understand that I can withdraw my child from all evaluations at any time and that participation in such activities will never affect access to program services. Any questions or concerns can be forwarded to email@example.com.
I, the parent/guardian of the child named above understand, agree and give permission for such child to participate in the programs of Visions of Science Network for Learning, consent to any necessary first aid or emergency medical treatment being given or provided for the child, waive any claims against the Visions of Science clubs, or any of the Visions of Science representatives, employees or volunteers, in respect to any personal injury to such child/any other person/any loss of or damage to property, arising in any way at, from or in connection with the programs of Visions of Science Network for Learning. I am providing this waiver on behalf of such child and on behalf of my spouse and any other family members or other persons who might be entitled to assert such a claim as well as on my own behalf.
By checking this box, I acknowledge that I have read the above and fully understand its contents and voluntarily agree to all of the terms and conditions. I acknowledge and consent to all information shared in this form.
Parent/Guardian Signature (Please Type Your Full Name)
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