Central PA’s Nonprofit Center for the Arts

Girls In STEM

Registration Form

An asterisk (*) indicates a required field.

Child First Name: *

Child Last Name: *

Nickname:

Grade child is/will be enrolled in on the date of the program: *

Birthdate: *

Any pertinent medical information (allergies, prescription medicine, etc.): *

I understand that food may be consumed during this event and I have disclosed my child's known allergies and medical information. Please agree to this

Child's Primary Physician: *

Physician's Phone Number: *

Health Insurance Carrier: *

Policy Number: *

Any other pertinent information (special learning abilities, for example): *

Parent First Name: *

Parent Last Name: *

Address Line 1: *

Address Line 2:

City: *

State: *

Zip: *

Parent Email Address: *

I would like to be added to Whitaker Center's e-mail list.

Parent Phone: *

Who is allowed to pick up your child? *

Emergency Contact Name: *

Emergency Contact Phone: *

Select session: * Please select a session

There are currently no sessions available for the grade selected.

Total: $0

TERMS

By submitting this registration form to Whitaker Center for Science and the Arts, I hereby certify that all of the information it contains is correct and accurate. I authorize my child to participate in Whitaker Center's Girls in STEM program and all of its activities, including travel within walking distance of Whitaker Center. If I or the Emergency Contact listed above cannot be reached in the event of an emergency, I hereby give permission to the EMT, physician, or other provider of medical services selected by Whitaker Center, to hospitalize, secure proper anesthesia, order medication or perform other medical procedures on an emergency basis for my child until such time as I am able to authorize medical services personally.

I release Whitaker Center for Science and the Arts and any of its components from any and all claims, costs and liabilities due to accidents, injury or other harm to my child. I agree to all stated terms and conditions.

I agree to all stated terms and conditions. Please agree to this

CANCELLATION POLICY

In order to accommodate every child who wants to attend our events, we require at least 4 weeks' notice for cancellations and full refunds. Cancellations made with less than 4 weeks' notice will not receive a refund.

I have read the cancellation policy and understand the terms. Please agree to this

PERMISSION TO PHOTOGRAPH

I give Whitaker Center for Science and the Arts permission to use my image or my child’s image for internal publications, on Whitaker Center’s website, and for Whitaker Center publicity in external publications such as local and regional newspapers and magazines. There is no expiration date on this permission and I will not seek compensation for any such usage.

Yes, I give my permission

No, do not use my image or my child's image

LATE PICK-UP POLICY

A fee of $15 per :15 minutes past the established pick-up time frame for this program will be charged to the payment method on file for each incident. Pick-up time will be reiterated in the pre-arrival e-mail sent from our educators.

I agree to the terms of the late pick-up policy and authorize Whitaker Center to charge my payment method if/when this policy is violated. Please agree to this

ELECTRONIC CONSENT

I agree to conduct transactions by electronic means, which includes signing this document electronically by typing my name as it appears on my state-issued ID: "Yes" is required

Yes

If you do not agree to conduct transactions electronically, please contact our Education Manager at education@whitakercenter.org to obtain a hard copy form of waiver.

Your registration is only complete and confirmed when you receive a confirmation by email.