STEM Enrichment Registration Form

Part I. Session Dates

Select a Session *

It Glows Green: 6/26/23 - 6/30/23
Fish Fraud Forensics: 7/17/23 - 7/21/23
It Glows Green: 7/24/23 - 7/28/23

Part II. Participant Information

Student Name *

First

Middle

Last

Nick Name

Date of Birth *

Age

Pronouns

Please select t-shirt size

Small
Medium
Large
Extra Large

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Part II. Participant Education

School Name

Grade Entering, Fall 2023

Please list any science courses you have completed, or are currently enrolled in:

Part III. Parent/Guardian Information

Parent/Guardian

Name *

First

Last

Home Phone

Cell Phone

Email *

Part IV. Emergency Contact

Emergency Contact

Layout

First and Last Name

Relationship

Layout

Phone

Email

Secondary Phone

Part IV. Emergency Consent Form

Emergeny Consent Form

If you cannot be reached, and in order for Gloucester Biotechnology Academy to protect your child in the event of a medical emergency, please complete and sign the following information. This form will accompany your child to the hospital so that medical treatment can be provided. There will be no nurse on-site at Gloucester Biotechnology Academy.

Statement

I hearby authorize Gloucester Biotechnology Academy staff to give consent for any emergency medical and/or surgical treatment deemed necessary for my child during program hours in the event I cannot be reached: *

Yes
No

Parent/Guardian Name *

First

Last

Date *

Participant's Doctor *

First

Last

Doctor Phone

Date of last tetanus shot:

Health Insurance Co. *

Group # *

Chronic Illness or Allergies

Current Medications

Does your child have an Individualized Education Program or any learning/behavior challenges? If so, please describe:

Does your child have any limitations, physical or otherwise, that would affect his/her ablity to safely participate in the program without posing any undue risk to him/herself or others?

Yes
No

Permission to Photograph

Do you authorize Gloucester Biotechnology Academy to use, reproduce, publish, and distribute my name, voice, likeness, photograph and/or any other representation of me in printed materials or other media now known or hereinafter developed in connection with materials Gloucester Biotechnology Academy publishes, distributes, displays, transmits, or exhibits? Further, I waive the right to any proceeds or other benefits derived from such printed materials and other media. *

Yes
No

Parent/Guardian Name *

First

Last

Date *

Parental Agreements

1. I give permission for my child to attend Gloucester Biotechnology Academy’s STEM Enrichment Program.

2. Gloucester Biotechnology Academy agrees to notify the parent/guardian when the child becomes ill and the parent/guardian will arrange to have the child picked up as soon as possible.

3. The parent/guardian agrees to inform Gloucester Biotechnology Academy within 24 hours or the next business day after his/her child, or any members of the immediate household, has developed a reportable communicable disease, as defined by the State Board of Health, except for life-threatening diseases which must be reported immediately.

4. The parent/guardian agrees to notify Gloucester Biotechnology Academy of any expected absences that the child will have during the length of the program.

5. Gloucester Biotechnology Academy is not responsible for any loss or injury that might occur on the premises of 55 Blackburn Center.

6. I release and forever discharge the Gloucester Biotechnology Academy from any claim or action whatsoever which arises or may arise on account of any first aid, medical treatment, or service rendered in connection with activities conducted as a volunteer. I also agree to indemnify and hold-harmless the Gloucester Biotechnology Academy against any such claim or action brought by any third-party (including any other family member) or, if the volunteer is under 18 at the time the claim or action arises, brought by the volunteer.

7. Anyone under the influence of drugs and/or alcohol will not be permitted to participate. Smoking must be in designated areas only.

8. I acknowledge that all the information on this form is truthful and accurate.

I understand and agree to the eight (8) Parental Agreements outline above: *

Yes, I understand and agree to the terms listed above.

Did someone from the Academy present at your child's school?

Yes
No

Submission

Please note that after submission, your application is final and you will not have the opportunity to make changes. Be sure that all information is complete and accurate prior to submitting.

Thank you for your interest in our Summer STEM program!

STEM Enrichment Registration Form

Part I. Session Dates

Part II. Participant Information

Part II. Participant Education

Part III. Parent/Guardian Information

Parent/Guardian

Part IV. Emergency Contact

Emergency Contact

Part IV. Emergency Consent Form

Emergeny Consent Form

Statement

Permission to Photograph

Parental Agreements

Submission

Mission

Gloucester Marine Genomics Institute