Science Day 2010 Registration Form for 3rd-6th Grade Groups
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To register you must fill out and SUBMIT this form by pushing the Submit Form button at the bottom.
Confirmation of receipt will result as soon as you submit the form - please read the message there!

1. Student Information (Please use this form for as many as 10 children in your group. If you are accompanying more than 10 children, please fill out this form as many times as you need.)

A. Names and Grades. Please add school and t-shirt size if you know them, but they are not required information.
Name Grade T-shirt School
   

2. Group Leader Information (please fill in for the adult who will be responsible for the group)

Role (e.g. teacher, troop leader, parent accompanying a group of friends)
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Cell Phone
Home Phone
E-mail for confirmation and updates only!

If you are a teacher who would like to take advantage of teacher benefits provided, please indicate your school and grade here:
                          

3. Waiver

In order to participate, you must give permission for photos of the student, or any parent, guardian, or teacher that are taken at the event to be used on the college website, brochures, or shown on local news. No identifying information will be attached to photos. You must also agree that an adult will be present who can take responsibility for the student at any time through the day. All activities are active and interactive classroom activities. It is up to the responsible adult and student to determine if the student can participate in each activity, and if there is any hazard such as an allergen present.

Type your name here (as an electronic signature):         

Is there anything else you need to let us know?


Randolph College Society of Physics Students.  2500 Rivermont Avenue, Lynchburg, VA 24503
Copyright © 2005 Tracey Wellington. All rights reserved.
Revised: 03/02/10