Student’s Name 

Grade  Age 

Parent’s Names 

Address 

City  State  Zip 

Your Email (required)
 

Phone 

Emergency Contact Name 

Emergency Contact Phone 

Please read the following information. By checking the boxes, you are agreeing to the accompanying statements.

Gateway to Science Liability Release  I release Gateway to Science and individuals from liability in case of accident during activities related to Gateway to Science, as long as normal safety procedures have been taken.

Photo Permission to Gateway to Science I give my permission to Gateway to Science to use photos of my child taken during camps, to be used by Gateway to Science for publications and media purposes.