Hands On!

First Name (Student): *

Last Name (Student): *

Gender: *

Female

Male

Age: *

Grade Level: *

School: *

Home Address: *

State/Province/Region: *

City: *

ZIP/Postal Code: *

Country: *

E-mail Address: *

(Please enter your most commonly used account.)

First Name (Parent/Guardian): *

Last Name (Parent/Guardian): *

Home Telephone: *

Mobile Telephone:

Emergency Contact (First & Last Name): *

E-mail Address (Parent Guardian): *

(Please enter your most commonly used account.)

Relationship to Student: *

Terms of Arrival & Departure: *

My child will be dropped off and picked up from the program site.

My child will arrive and leave independently to and from the program site.

Terms of Agreement: *

Yes, I agree to have my child, participate in the Hands On! Program for the entire 8-week program (8 sessions), including fieldtrips (to be scheduled). The student must also attend an Award Ceremony upon completion of the program. I further agree to have my child arrive on time, ready to listen and share their ideas.

No, I do not agree.

Terms of Workshop Equipment & Materials: *

I allow my child to use equipment and materials for all workshops. I understand that certain workshops will expose the students to certain chemicals and/or machinery. All use will be supervised by an adult, and students will use goggles and gloves if necessary.

I do not allow my child to use any equipment or materials.

Terms of Emergency Care: *

I, the Parent/Guardian, allow Weeksville to call 911 and obtain immediate medical care in case of an emergency and the emergency contact indicated above cannot be reached immediately.

I, the Parent/Guardian, do not allow emergency medical care.

Terms of Lunch During Workshops: *

I understand that students are required to provide their own lunch during the program and once a workshop begins, students are not allowed to leave the premises to purchase food. My child will bring lunch to Weeksville.

Please list all of your child’s allergies/medical conditions:: *

Programs