Super Kid Science Program Registration Form

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These programs are run by Super Kid Science, LLC of Holly Springs. You may visit our website and see our programs and opportunities. Our web address is https://superkidscience.com/. We can be contacted at superkidscience@gmail.com or at 919-995-3477.

Email *

Check the boxes for the program(s) you wish to register. Make sure you click the submit button for this form when you are done. You will be sent an invoice to the email you listed above and the payment will need to be made within 3 days to secure the reservation. You will also receive an email receipt with the responses from this form for your records. Please email us at superkidscience@gmail.com if you do not receive an invoice or contact attempt from us within 24 hours. Thank you! *

Trailblazer Summer Fun with Finn , July 27-29 ($300, you will receive a bill in the next 24 hours). https://superkidscience.com/programs-and-class/trailblazer-summer-camp-2-2/

One hour science fun session ($30 plus $20 per additional participants). https://superkidscience.com/programs-and-class/private-sessions/

Party, festival booth or Private Event. We will contact you to schedule and then email an invoice. https://superkidscience.com/programs-and-class/schedule-a-party-or-private-event/

Private Tutoring. We will contact you to schedule and then email an invoice. https://superkidscience.com/programs-and-class/private-tutoring/

Other. superkidscience@gmail.com

waiting list for a full camp (no charge)

Required

First name of participant. *

Last name of participant. *

Age *

Parent or emergency person's name. *

Best Contact Phone Number. *

Phone number(s) where you want to receive text messages. We send texts to communicate about our locations, changes and other program information. *

Other emergency contact information (optional)

Home address *

Medical needs and allergies we should know about. (optional)

What else do we need to know about the participant to help them have the best possible experience? (optional)

Photo Permission. Super Kid Science publishes photos in our digital albums to share our adventures, on our website and in our promotional literature and digital posts. No names are ever used in our publications. *

I give consent for participant photos to be published as described above.

Please do not publish photos of this participant

Super Kid Science takes safety and well being seriously. Marilyn Jesrani is certified in first aid, CPR and as an ACA kayak instructor guide. Unfortunately, accidents and mishaps are always possible (and very likely with outdoor activities, especially minor incidents like splinters, scratches, etc..). In order to participate in our programs, you must agree that Super Kid Science, people working our programs and the owners of the locations where our programs are held can not be held liable for incidences, illnesses, injuries or loss of property. Any medical expenses that may occur must be paid by your family and through your personal medical insurance. *

I agree

Super Kid Science is not responsible for lost, stolen or damaged property including cell phones and electronics. Always wear clothes and shoes that can get dirty to our programs. *

I agree

I give Marilyn Jesrani of Super Kid Science consent to seek medical treatment for my child or this participant in an emergency. *

I agree

Do you give the participant permission to participate in water activities such as boating and swimming, and if yes, what is their swimming ability? *

Yes, but can not swim.

Yes, beginner swimmer

Yes, can float, hold breath under water and swim to side of pool.

Yes, can float, hold breath under water and swim at least 2 laps in a pool

For the purpose of life vests....

Participant is under 50 pounds

Participant is between 50 to 90 pounds

Participant is over 90 pounds

Not applicable

Clear selection

I allow my child to drive in a car with Marilyn Jesrani or another Super Kid Science leader that is entrusted by her. Please check all that apply. *

Yes

My child must be in a car seat and I will bring the car seat to the program.

I give permission for my child to sit in the front seat

No or is not applicable to this program.

Required

Please do not allow your child to bring toys or electronics so that they may have a full immersive experience. If you would like your child to have a cell phone as we never deny children contacting their parents, please have them store them in their back packs during the program. We can not be responsible for lost or broken items. *

I understand

For Kayaking and outdoor activities, wear clothes appropriate for getting wet, dirty and the weather. Closed toed shoes (sneakers) are required for camps and other woodland activities. Kayakers should wear water shoes or shoes that can get wet. *

I understand

Not applicable to the program I am signing up for

For the safety of others, please do not bring any child, friend or family member to a program who has vomited, had diarrhea or has had a fever in the past 24 hours. If you submit a doctors note for your sick child, we will give you a refund for the day.

I understand

Clear selection

If you purchased a one hour science fun session, please state how many people you would like included in the session. The cost of the session is $30 for the first person plus $20 for each additional person.

If this is a gift and you would like us to send a certificate, please give us the name and address you would like us to send the certificate to. We can send certificates by email or by the US postal service. *Write any messages you would like us to include with the certificate such as "happy birthday Kate, love Aunt Alice".

Where did you hear about our program(s). If from a teacher, what is the name of the teacher and school?

You will receive an invoice for the program you registered for through email. Please pay the invoice within 3 days to finalize your reservation. If a program is cancelled due to COVID 19 restrictions weather or other circumstances, you will receive a full refund.

I understand

Clear selection

Please type your name to confirm that you filled out this form and agree with the accuracy of your responses. You will be asked to sign a printed copy of your form on the first day of your program .

A copy of your responses will be emailed to the address you provided.

Submit

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