1. Gifted Student Summer Programs Registration

Dear Gifted Student Summer Program Participants and Parents,

Thank you for your interest in our 2014 summer Program(s). Please take a moment to answer all of the questions on this registration form

I look forward to working with you,
Dr. Demetrikopoulos

Melissa K. Demetrikopoulos, Ph.D.
Director of Scientific Communications
Chair, Division of Program Development and Assessment
Energetic Einsteins
GiftedInfo@BioPhi.org

* 1. Which week(s) of Gifted Programing are you registering for.

* 2. For the following questions please provide the information requested.

* 3. Please answer the following question with the Month Day and Year.

Date of Student's birth
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* 4. Gender

* 5. Please indicate type of gifted program that your child participates in during the school year (mark as many as apply).

* 6. Current Grade Level (2013-2014 school year)

* 7. Student t-shirt size

* 8. Student receive one free t-shirt with registration. If you would like to purchase any additional t-shirts for your student or another family member, please indicate the number of each size that you would like to obtain below. Additional t-shirts cost $12 each.
Please do not include the free t-shirt in these totals.

* 9. Does your child have any physical, dietary, or other special needs? Please let us know if your child has any special needs. The program, as designed, requires physical activity. We are willing to work with individuals who wish to participate but who may need modifications to the format. Please contact us ASAP if this applies. We fully comply with the Americans with Disabilities Act.

* 10. Do any special arrangements need to be made for your child? Please let us know if your child has any special needs. The program, as designed, requires physical activity. We are willing to work with individuals who wish to participate but who may need modifications to the format. Please contact us ASAP if this applies. We fully comply with the Americans with Disabilities Act.

* 11. Please provide the following information. Please do not leave the question blank as we need a way to contact parents of registered students and a mechanism to provide them with information.
Some sort of a response is required for each line of this question. Please do not leave the questions blank and respond with none if there is no other response.

* 12. Please provide the following information. Please list two emergency contacts and notate if they can pick up your child.
Some sort of a response is required for each line of this question. Please do not leave the questions blank and respond with none if there is no other response.

* 13. How did you hear about the program? Please mark as many as apply.

* 14. By registering my child in this Program, I recognize that the program's activities, which may include a variety of physical activities both indoors and outdoors, could involve risk of physical injury or illness, and I assume the risks associated with these activities, knowing that despite precautions and supervision, not all risks can be prevented. Additionally, I give consent for the use of my child's photograph for educational purposes and promotion. I have/will have read the full Informed Consent Agreement and Assumption of Risk form and will provide a signed copy prior to my child's participation in the program. (A full copy can be requested from GiftedInfo@BioPhi.org and it will be posted on the website soon.)

* 15. We have found that gifted student have different learning needs. For example some gifted individuals are visual learners and have difficulty with auditory instruction---please let us know if you child needs any additional support for their learning style and please let us know if they excel/favor a particular learning style.

* 16. Is there any other important information that we should know?

* 17. Refer a Friend: If you know other students who may be interested in this program, please provide their contact information so that we can send them program information. As an incentive, you both will receive a discount if they attend.

* 18. If you are registering more than one child, please note this here so that you can receive the Sibling Discount.

* 19. If you can, please consider contributing to the scholarship fund so that financially needy deserving students can attend.

* 20. If you can contribute to the scholarship fund, and would like to be acknowledged on the website, please indicate how you would like to be acknowledged.

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