She Can STEM Academy Pop-up Event Registration 
December 17, 2022 from 11:30am-1:00pm at South Norfolk Library (801 Poindexter st. Chesapeake)
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Student Full Name* *
Date of Birth *
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Phone Number
Race/Ethnicity
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Current School *
Current Grade/Year *
Have you participated in She Can STEM Academy workshops in the past? *
Required
How did you hear about the STEM Pop-up Event? *
Parent/Guardian Name
Parent/Guardian Phone Number
Parent/Guardian Email
Does student have any allergies or special needs?  If so, please indicate.
There will be a fee of $15 for STEM supplies.  Payment can be made on the day of event. Cash or Card accepted. Will that be an issue for you? *
Release of Information: I hereby release and hold harmless Butterfly Village Incorporated, its officers, employees, agents, representatives, volunteers, heirs, executors, and assigns from all liability for personal injury, including death, as well as all property damage or loss arising out of my/my child’s participation in She Can Academy STEM and any travel/transportation-related to this program, whether paid for by myself or by Butterfly Village Incorporated. I understand that this release and indemnification release liability for the conduct of Butterfly Village Incorporated and its officers, employees, agents, representatives, volunteers, heirs, executors, and assigns.
Please type full name to agree to release of information statement
Photo Release: The undersigned gives permission to Butterfly Village Incorporated to use photographs and audio and/or video recordings of She Can Academy STEM for fundraising and/or marketing purposes. On occasion, with permission, Participant photographs may be included in promotional videos, websites, newsletters. ButterflyVillage respects the privacy of its participants and does not allow unauthorized visitors to photograph or video the camp or its Participants.
Please type full name to agree to photo release statement
Participation Consent: The undersigned consents to participate in any and all activities, including transportation (if applicable) to and from She Can Academy STEM activities, except those specifically prohibited by the participant’s physician.
Please type parent/guardian full name for participation consent
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