ARCHIVED-Registration page

Registration now Open for Winter-Spring semester 2018 !!
Our classes are held at Stocklmeir Elementary School, Cupertino .Click here for more information on our programs.
To Register please complete the form below and click continue . Our checkout process is completely secure (with Square).
We also accept checks made payable to "Petri-dish Science" .
Please email us at [email protected] or call at 408-663-1214 if you have questions and we will be happy to resolve it .

* Indicates required field

Child's name *

First

Last

Child's Grade *

Child's Gender *

School name *

Primary contact name *

First

Last

Relationship with child *

Gender *

Authorized to pickup child *

Yes

Primary email address *

Primary phone Number *

Secondary contact name *

First

Last

Relationship with child *

Gender *

Authorized to pickup child *

Yes

Secondary email address *

Secondary Phone Number *

Medical Information ( list any allergies or medications that the child has or write NA) *

Liability Release
I, the undersigned, in consideration of participation in the Programs / classes offered by "Petri-dish Science " , I agree to indemnify and release the Program , its officers, staff, employees and vendors , from any and all liabilities from any injuries which may be suffered by the above named child, arising out of, or in any way connected with participation in the classes or activities offered by the program. I acknowledge that I have read the above agreement and release, and fully understand that I have assumed all the risks of injury that may occur in the activities offered by the program. I hereby further authorize the Program as the agent for the above named child to consent to any medical diagnosis or treatment and hospital care rendered by and under the general supervision and advice of a licensed physician or surgeon in case of accident or illness during a session of any classes or activities offered by the program.

Terms and conditions *

I have read the terms and conditions and agree

Name *

First

Last

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