Gifted Student Summer Programs Registration 2014

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

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

Wizard Camp for Gifted Muggles June 23-27 (gifted student who completed 3rd-6th grade)

Are You Smarter Than a Rocket-Scientist? August 4-8 (gifted student who completed 5th-9th grade)

Brain Camp for Brainiacs August 11-15 (gifted student who completed 6th-11th grade)

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

Student Name: *

Parent/Guardian: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Country: *

Email Address: *

Phone Number: *

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

Date of Student's birth

Date

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* 4. Gender

Male

Female

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

Grade Skipping

Course Acceleration (ie 3rd grader in with 4th graders for one or more subjects)

Full-time gifted program

Pull out part-time gifted program

Other (please specify)

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

Please note any classes taken out of their current grade level

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* 7. Student t-shirt size

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult XXL

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* 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.

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult XXL

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* 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.

Yes

If yes, please list any physical, dietary,or other special needs that your child has, or make a notation that you will contact mdemetr@biophi.org to discuss.

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* 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.

Yes

If yes, please list these arrangements or make a notation that you will contact mdemetr@biophi.org to discuss.

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* 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.

Mother/Guardian-A name

Mother/Guardian-A email address

Mother/Guardian-A Cell phone

Mother/Guardian-A alternative contact

Father/Guardian-B name

Father/Guardian-B email address

Father/Guardian-B Cell phone

Father/Guardian-B alternative contact

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* 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.

Emergency Contact-A name

Emergency Contact-A email address

Emergency Contact-A Cell phone

Emergency Contact-A alternative contact

Can Emergency Contact-A pick up your child?

Emergency Contact-B name

Emergency Contact-B email address

Emergency Contact-B Cell phone

Emergency Contact-B alternative contact

Can Emergency Contact-B pick up your child?

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

Friend

Teacher

Gifted Association

School Gifted Program

Other Gifted Program

Flier

Energetic Einsteins Website

Other Website

Other (please specify)

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* 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.)

I agree to the above statements.

I do not agree to the above statements.

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* 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.

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

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* 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.

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

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

$10

$25

$50

$75

$100

$150

$200

$250

$300

$350

$400

$450

$900

$2000 Friend of Albert

$5000 Albert's Inner Circle

$10,000 Albert's Best Friend

Other (please specify)

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

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

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

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* 4. Gender

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

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

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* 7. Student t-shirt size

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* 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.

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

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

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* 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.

Question Title

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

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

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* 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.

* 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.