Stem Lab for Homeschool

Permission and Consent Form

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Session

Student Information

Full Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Current Grade Level(Required)

Student Home Address(Required)

Street Address City State ZIP Code

Parent/Guardian Information

Full Name(Required)

Relationship to Student(Required)

Primary Phone(Required)

Secondary Phone

Active Email Address(Required)

Enter Email Confirm Email

Home Address(Required)

(if different from student)

Street Address City State ZIP Code

Second Parent/Guardian Information

Second Parent/Guardian Name

Relationship to Student

Phone

Enter Email Confirm Email

Primary Emergency Contact

Full Name(Required)

Relationship to Student(Required)

Primary Phone Number(Required)

Alternate Phone Number(Required)

Secondary Emergency Contact

Would you like to add a second emergency contact?(Required)

Full Name(Required)

Relationship to Student(Required)

Primary Phone Number(Required)

Secondary Phone Number

Authorized Pick-Up

The following individuals are authorized to pick up my child from the STEM Lab program. Photo ID will be REQUIRED at pick-up.

People authorized to pick-up my child:(Required)

Full Name

Relationship

Phone Number

Use the “add” button to add multiple people.

Medical Information

Child’s Physician/Provider Name(Required)

Physician/Provider Phone Number(Required)

Health Insurance Carrier (optional)

Policy/Member Number (optional)

Does your child have any allergies?(Required)

(food, medication, insect, environmental, latex, etc.)

Yes

Allergies(Required)

Does your child have any medical conditions, diagnoses, or health needs that staff should know about?(Required)

Yes

Medical conditions, diagnoses, or health needs(Required)

Does your child have any activity restrictions or physical limitations?(Required)

Yes

Activity restrictions or physical limitations(Required)

Please share any sensory, behavioral, emotional, communication, or learning needs so we can better support your child(Required)

Accommodation and Accessibility Information

To help us provide a safe, supportive, and accessible learning environment, please share any accommodations, supports, or strategies that may help your child participate successfully(Required)

If your child needs accommodation related to access, mobility, communication, sensory needs, medical needs, or learning support, please describe that need above. Advance notice is appreciated so that the STEM Lab can review requests and coordinate support as appropriate.

Best contact for accommodation follow-up (if different from parent/guardian above):(Required)

Registration and Participation Limits(Required)

I understand that this STEM Lab opportunity is intended as a one-time visit per student for the current offering, unless otherwise invited by the STEM Lab.
I understand that submission of this form does not guarantee participation and that enrollment is subject to space availability, review of submitted materials, and confirmation from the STEM Lab.

I understand and agree

Arrival, Dismissal, and Supervision(Required)

I understand that detailed drop-off and pick-up procedures, arrival windows, dismissal instructions, and any site-specific access requirements will be shared separately by email before the program date.
I understand that entry to the facility is conditioned on compliance with all site access and safety procedures, including screening for dangerous or prohibited items, and that refusal to comply may result in denial of entry.
I understand that my child must be signed in and signed out in accordance with STEM Lab procedures.
I understand that STEM Lab staff are responsible for participants only during official program hours, after check-in is complete and until authorized dismissal.

I understand and agree

Health and Safety Acknowledgment(Required)

I understand that I should not send my child to the program if they are ill, have a fever, are vomiting, have diarrhea, or are experiencing symptoms that could make participation unsafe for them or others.
I agree to notify the STEM Lab as soon as possible if emergency contact information, medical information, allergy information, or pick-up authorization changes before the program date.

I understand and agree

Participation Acknowledgment(Required)

I understand that my child will participate in hands-on STEM learning activities that may include, but are not limited to, design challenges, movement within classroom/lab spaces, use of common educational tools and materials, collaborative group work, and guided demonstrations.
I understand that all reasonable precautions will be taken to support student safety; however, participation in educational programs and activities involves some inherent risk of minor injury, illness exposure, accident, or property loss.
I confirm that my child is physically and emotionally able to participate in program activities, except as disclosed in this form.

I understand and agree

Medical Treatment Authorization(Required)

In the event of an emergency, and if I cannot be reached immediately, I authorize STEM Lab staff and/or their representatives to secure appropriate emergency medical care for my child, transportation to a medical facility, as deemed reasonably necessary.
I understand that I am responsible for any medical expenses incurred on behalf of my child.

I understand and agree

Release of Liability(Required)

To the fullest extent permitted by law, I, on behalf of myself and my child, release and hold harmless the STEM Lab, its sponsoring organization(s), affiliates, officers, employees, volunteers, contractors, partners, and representatives from and against claims, liabilities, damages, losses, or expenses arising out of or related to my child’s participation in the program, except to the extent caused by gross negligence or willful misconduct.
I understand that this release includes ordinary risks associated with participation in educational activities, movement through program spaces, and use of age-appropriate supplies, tools, and equipment under supervision.

I understand and agree

Behavioral Expectations and Code of Conduct(Required)

I understand that students are expected to follow staff directions, remain with their assigned group, stay in designated areas, treat other students, staff, volunteers, and guests respectfully, and use equipment, materials, and facilities appropriately and safely.
I understand that behavior including, but not limited to, aggression, threatening/inappropriate language, harassment, repeated refusal to follow directions, leaving supervised areas without permission, intentional misuse of equipment or materials, or other conduct that disrupts the program or creates a safety concern may result in immediate parent/guardian contact and may require early dismissal from the program.
I understand that the STEM Lab reserves the right to remove a student from participation when conduct compromises the safety, well-being, or learning environment of the student or others.

I understand and agree

Photo, Video, and Media Release

I give permission for my child to be photographed, video recorded, and/or included in audio, digital, or printed materials for educational, promotional, reporting, archival, or public relations purposes related to the STEM Lab and its partners.

I understand and agree

Transportation Acknowledgment(Required)

I understand that STEM Lab staff are responsible for my child only during official program hours and after my child has been properly checked in.

I understand and agree

Attendance and Pick-Up Acknowledgment(Required)

I understand that timely drop-off and pick-up are required. I understand that repeated late pick-up may affect my child’s invitation to future events.

I understand and agree

Communication Consent(Required)

I understand that the STEM Lab may use the active email address and phone number provided on this form to send confirmations, program logistics, arrival and dismissal instructions, reminders, updates, and urgent communications related to my child’s participation.

I understand and agree

Personal Property Acknowledgment(Required)

I understand and agree to the following:

I understand that my child should bring only items necessary for participation. The STEM Lab, its sponsoring organization(s), affiliates, employees, volunteers, contractors, partners, and representatives are not responsible for lost, stolen, or damaged personal property brought to the program.

Parent/Guardian Certification(Required)

I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that failure to disclose relevant medical, behavioral, or support information may affect my child’s safe participation.
I have read and understand this permission form, liability waiver, emergency information, and related acknowledgments. I voluntarily permit my child to participate in the STEM Lab program.

I understand and agree

Signature

By signing below, I certify that I have read, understand, and agree to all information, waivers, and acknowledgments provided in this form.

Printed Name(Required)

Please type your full name