STEMBoost Summer 2019 Workshop Sign Up Form

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Time: 3:00-5:00pm. Venue: Omei Academy, Cupertino, CA.
Donation: $30/day to cover for materials.
Please donate via PayPal to stemboost.org@gmail.com as soon as you sign up to guarantee your space.

Email *

Do you want to sign up for the July 14th: Infection Detection & Acids and Bases Workshops? (choose 1 for yes, 0 for no)

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Do you want to sign up for the July 21st: Acceleration and Gravity & CSI: Cupertino Workshops? (choose 1 for yes, 0 for no)

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Do you want to sign up for the July 28th: Thermodynamics & Botany Bonanza Workshops? (choose 1 for yes, 0 for no)

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Do you want to sign up for the August 4th: Java Programming & Artificial Intelligence Workshops? (choose 1 for yes, 0 for no)

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Do you want to sign up for the August 11th: Natural Selection & Physics Workshops? (choose 1 for yes, 0 for no)

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Student Name *

Student grade *

Student School Name *

Additional comments

Phone number *

Necessary Medical Accommodations (allergies and sensitives, including airborne/skin contact and whether your child carries an epipen, and any other conditions or special circumstances we should be aware of) *

Legal Release - permission *

My son/daughter(s), has my permission to participate in the STEMBoost Summer STEM Workshops of 2019 at Omei Academy. I hereby agree to hold harmless the STEMBoost Board of Directors, officers, instructors, volunteers and Kennedy Middle School and staff and/or their members with respect to any and all damages or expenses which may be incurred, suffered or required to be paid by reason of this activity before, during or after each workshop. In addition, I hereby authorize STEMBoost to use, modify, reproduce, distribute photograph/videotape of my child for publicity and promotional purposes.

Required

Legal Release - medical *

In the event of illness or injury, I consent to all routine and/or emergency medical treatments and/or services prescribed by the attending doctor, surgeon, dentist or other health care provider and to the administration and performance of all examinations, treatments, anesthetics, operations, and other procedures which are deemed necessary or advisable by the attending doctor at the scene and/or at the hospital or other medical facility. Above are my child's medical information and statements, and the telephone number where I can be reached during the workshop(s), should it be necessary to contact me in the event of an emergency.

Required

Parent Signature *

Parent Name *

Send me a copy of my responses.

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