Registration Form – Roots 2 STEM

COURSE REGISTRATION

Please complete the course registration form below and also please read and approve the consent and waiver document.

Name on Order - from the Roots 2 STEM Store *

First

Last

Home Address *

City *

Postal Code *

Name of child attending the program *

First

Last

Birth Date (month/day/year) *

Age *

Grade

Area of Interest

Program Participation (Enter program, ie Jr Engineers)

Name of Parent / Guardian (primary) *

First

Last

Cell Phone Number for Parent / Guardian (primary) *

Home Phone Number for Parent / Guardian (primary) *

Email for Parent / Guardian (primary) *

Name of Parent / Guaradian (secondary)

First

Last

Cell Phone Number for Parent / Guardian (secondary)

Home Phone Number for Parent / Guardian (secondary)

Email for Parent / Guardian (secondary)

Is there another person(s) authorized to pick up the student? *

Yes (specify below)
No

Authorized pick up contact #1

First

Last

Cell Phone Number for authorized pick up contact #1

Email for authorized pick up contact #1

Authorized pick up contact #2

First

Last

Cell Phone Number for authorized pick up contact #2

Email for authorized pick up contact #2

Does your child have any allergies? *

Yes (specify below)
No

Specify allergies and severity.

Does your child have any other medical or health concerns that the team at Roots 2 STEM should be aware of?

Please indicate any health of physical challenges in the space above or provide a letter for greater detail.

Has your child been assessed with a special learning need? *

Yes (specify below)
No

Special needs

Does your child have or require a special aid? *

Yes (specify below)
No

Special aid

Order Number for the Purchased Program - from the Roots 2 STEM Store *

When you buy a program on the store it will show you an order number. We need this and the name you used to order so we can link this registration to the correct order.

Name on Order - from the Roots 2 STEM Store *

How did you hear about Roots 2 STEM?

Message

Consent and Waiver Information

I consent to the release of any photographs, audio-visual productions, print and electronic communications produced by Roots 2 STEM for the purpose of developing promotional materials. Personal image and information will be protected in compliance with regulations regarding the protection of personal information and will be kept for a period of two program years.

Every care and attention will be given to the well-being and safety of the participants in a Roots 2 STEM program. All participants under the age of 18 will be supervised while participating in the program. A high standard of conduct is expected at all times. Any Unacceptable Behaviour, as set out in our Code of Conduct, will be dealt with by the staff or volunteers of Roots 2 STEM. Unacceptable Behaviour may result in the participant’s removal from the program.

I authorize Dean White or designated agents (staff or volunteers with or employed by Roots 2 STEM) to obtain medical treatment in emergency situation for myself (if unable to do so) or my child (where I cannot be reached in time) and to authorize the treating physician to provide emergency medical services.

I understand that I am responsible for any medical expenses and that the absence of health insurance does not make Roots 2 STEM responsible for payment of medical expenses. This medical authorization will remain in effect for one year from the date of registration. I have carefully read this waiver and fully understand it.

I understand that risk of injury is inherent in any activity and I, on behalf of myself/my child, knowingly and voluntarily accept that risk. I waive and release, for myself, and my heirs and executors, Dean White individually and Roots 2 STEM and its staff and volunteers from any and all claims or damages of any kind arising out of participation in the Roots 2 STEM program. I have carefully read this waiver and fully understand it. I understand that by acknowledging that I’ve read this document that I am waiving certain legal rights, including the right to sue.