Student's Name *

First Name

Last Name

Parent/Legal Guardian's Full Name *

First Name

Last Name

Phone

(###)

###

####

Racial/Ethnic background *

Hispanic/Latino

Black/African American

White/Caucasian

American Indian/Alaskan Native

Asian

Other

Choose the subjects you are interested in *

Mixology (Chemistry - Grade K-4)

Robotics (Grades 4 and up)

BioTechnology (Grades 3 and up)

Fossil Frenzy (Natural History - Grade K-4)

French (Grade K-4)

Mini-Bridge Building (Grades 5 and up)

Parent/Guardian Child Code Of Conduct Form *

Below is a set of rules that must be followed. Participation in this program is a privilege that can and will be revoked if your child refuses to adhere to them. Please read and review these rules. We appreciate the time and effort you take in discussing this matter with your child. 1. Abusive language or bullying will NOT be tolerated. 2. Misuse of Ekaza’s facilities, supplies, and equipment will revoke their privilege to be in the program and you will be held responsible for any damages. 3. All participants will be expected to share clean-up responsibilities at the laboratory. 4. We REQUIRE parents to BE ON TIME picking up children from the program. (Your child will lose their privilege to attend this program if there is frequent abuse of this requirement.) 5. Parents/Guardians will also be required to conduct themselves in an appropriate manner when at Ekaza. 6. Child must be signed out daily (first and last name). 7. Unless recommended with a written note provided by special services (Physician, Psychologist, or social services), a child should not use their personal toys, cell phone, or any gaming device during a session at Ekaza. My child fully understands that their actions are a direct reflection of Ekaza, and they are expected to act in a responsible manner. We have read and agree to this set of rules put forth by Ekaza-Bridging The Gap.

Photo and Video Release *

I give permission to Ekaza-Bridging The Gap to take photographs and/or videos of my child and allow Ekaza-Bridging The Gap to use such photographs and/or videos of my child for any lawful purpose, including, for instance, such purposes as publicity, illustration, advertising, and web content. I have read and understand the above