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Next Generation 2010
Student Registration
Organization
Session
Employee Name
Relationship to Child

Note: To complete this registration form, you will need the driver license number and date of birth for anyone that will be driving your child to STARBASE or picking them up after the program.

Child Information
Child's Last Name
Child's First Name
Gender   
Date of Birth
Ethnicity   (reported in summary form only)
Child's School
District
Grade Level  in Fall of 2010
Special Learning Needs
Special Health Needs
T-Shirt Size
Street Address
City
State
Zipcode
Click here if you have more children that will attend STARBASE
 
Child's Last Name
Child's First Name
Gender   
Date of Birth
Ethnicity   (reported in summary form only)
Child's School
District
Grade Level  in Fall of 2010
Special Learning Needs
Special Health Needs
T-Shirt Size
 
Child's Last Name
Child's First Name
Gender   
Date of Birth
Ethnicity   (reported in summary form only)
Child's School
District
Grade Level  in Fall of 2010
Special Learning Needs
Special Health Needs
T-Shirt Size
 
Child's Last Name
Child's First Name
Gender   
Date of Birth
Ethnicity   (reported in summary form only)
Child's School
District
Grade Level  in Fall of 2010
Special Learning Needs
Special Health Needs
T-Shirt Size
Family Information
First Parent (the Parent employed at )
Last Name
First Name
Position   at
Work Email
Home Email
Work Phone
Home Phone
Mobile Phone
Use the same address as the Child
Street Address
City
State
Zipcode
Second Parent
Last Name
First Name
Employer
Email
Phone
Mobile Phone
Use the same address as the Child
Use the same address as the First Parent
Street Address
City
State
Zipcode
Contribution
A $60 per child minimum charitable contribution made at the time of registration. Please note that your company is not financially sponsoring this program. STARBASE is a 501(c)3 nonprofit organization whose mission is to increase the knowledge, skills, and interest of youth in science, math, technology and engineering, and relies on your support to be able to offer this unique and high quality program to you.  The true costs of the program exceed $250/child. The STARBASE Board of Directors request that you consider supporting STARBASE at a higher level in order to help offset the real program costs and our school-year programs that serve inner city kids.
I plan to contribute $
I would like to use my credit card or PayPal to make my contribution.
You will be prompted to enter payment details after this form is submitted.
I will pay by check.
Please mail your check to STARBASE MN, 659 Mustang Ave, St. Paul, MN 55111. In the notes section on your check, please write your child's name.
A thank you letter will be mailed that can be used as a receipt for tax purposes. Who should receive this letter?
Last Name
First Name
Street Address
City
State
Zipcode
Emergency Contact Information (in case parents cannot be reached)
Last Name
First Name
Relationship to Child
Phone
Emergency Instructions
Volunteer Participation
Volunteer Options Classroom Assistant  (Day 1 Day 2 Day 3 Day 4 )
  Scientist/Engineer Talk (Day 3, 12-12:30)
Volunteer
Last Name
First Name
Relationship to Child
Email
Phone
Comments
Security Information
Due to security requirements at the Minnesota Air National Guard Base, all adults entering the base must provide the information below which will be routed through Base Security. Please fill in the information completely for any adult that will be picking up or dropping off your child. This information is required at the time of registration. In addition, adults must show a photo ID upon entry. Thank you.
Driver One
Last Name
First Name
Date of Birth
Driver's License No.    State
Driver Two
Last Name
First Name
Date of Birth
Driver's License No.    State
Driver Three Use for additional drivers
Last Name
First Name
Date of Birth
Driver's License No.    State
Driver Four Use for additional drivers
Last Name
First Name
Date of Birth
Driver's License No.    State
I hereby grant permission for the aforementioned minor to participate in the STARBASE program listed above. I understand that participation is voluntary. I also understand that STARBASE Minnesota, Inc. reserves the right to terminate participation in the program when it is deemed to be in the best interest of either the participant or the program. I also acknowledge that photographs and video may be used from time-to-time to document and promote STARBASE Minnesota activities and hereby consent to the use of my child's image for these purposes unless otherwise indicated below. I take full responsibility for any damage that might occur to government or STARBASE property caused by my child. I further agree not to hold the United States Government, the State of Minnesota, the Minnesota National Guard, its officers, employees and agents, STARBASE Minnesota staff or volunteers supporting the program, liable for any reason as a result of participation in this program.
  Check this box to complete registration for your child to participate according to the terms above.
Comments
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Copyright © STARBASE Minnesota. All rights reserved. Last updated June 9, 2010 .