REGISTER Collins

Registration for Collins Elementary Spring semester 2019
Please complete the form below and click the continue button to register .
Schedule information :

Grades : 2nd , 3rd , 4th and 5th Grade
Location: The Art Room (Beside the GLC)
Price: $220.00 for 11 classes
Day and Time: Wednesdays , 3:30pm - 4:45 pm
Duration: 02/06/2019 to 05/08/2019
Dates: 02/6 ,02/13, 02/27, 03/06, 03/13, 03/20, 03/27,04/10, 04/24,05/01,05/08

Registration Form

* 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 Petri-dish Science Program , its officers, staff, employees , independent contractors , volunteers 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 Petri-Dish Science 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 Petri-dish Science 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 , camps or activities offered by the Petri-dish Science program.

Terms and conditions *

I have read the above terms and conditions and agree

Name *

First

Last

Image/Video Permission *

I grant permission to post images/videos of my child on the Petri-Dish Science Website as part of semester end program highlights .

Submit and Continue

​Registration for Collins Elementary Spring semester 2019Please complete the form below and click the continue button to register .Schedule information :

Registration Form

Contact Us

Registration for Collins Elementary Spring semester 2019
Please complete the form below and click the continue button to register .
Schedule information :