STARBASE Duluth Summer STEM 2018
  Registration


Waiting List Only

I acknowledge that I am an employee of

Employee Name
Employee Email (your email at )
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 attending graduation.

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 2018
Special Learning Needs
Special Health Needs
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 2018
Special Learning Needs
Special Health Needs
 
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 2018
Special Learning Needs
Special Health Needs
 
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 2018
Special Learning Needs
Special Health Needs
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
Emergency Contact Information (in case parents cannot be reached)
Last Name
First Name
Relationship to Child
Phone
Emergency Instructions
Scientist and Engineer Volunteer Opportunity
We invite all scientists and engineers to share a short demo related to an aspect of your or your corporation's work and information about your STEM career with our summer program participants. As a volunteer scientist or engineer, you will present a short, interactive demo of your choice to three small groups. We can work with you on ideas for your demo. Help us inspire a future in STEM with our summer program participants! This event is held on day 3 of the summer program and runs from 12:00 pm to 12:30 pm, arriving at 11:45 am to set up.
Volunteer Options Scientist/Engineer Talk (Day 3, 12-12:30)
Volunteer
Last Name
First Name
Relationship to Child
Email
Phone
The STARBASE volunteer coordinator will contact you soon with more information about this opportunity.
Classroom Volunteer
A few weeks before the start of the program, you will receive an email with information about classroom volunteer opportunities. You will be able to sign up to volunteer in your child's classroom at that time.
Security Information (required for all adults, drivers and non-drivers)
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 enetering the base, whether they are driving or not. This information is required at the time of registration. In addition, adults must show a photo ID upon entry. Thank you.
Adult One
Last Name
First Name
Date of Birth    
Driver's License No.    State
U.S. Citizen?
Adult Two
Last Name
First Name
Date of Birth    
Driver's License No.    State
U.S. Citizen?
Adult Three Use for additional adults
Last Name
First Name
Date of Birth    
Driver's License No.    State
U.S. Citizen?
Adult Four Use for additional adults
Last Name
First Name
Date of Birth    
Driver's License No.    State
U.S. Citizen?
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.
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