VTS - S.T.E.M Registration forms must be completed and submitted along with the $25.00 registration fee in order to hold your scholars place. The fee per session is $60.00. Every student is required to submit a health forms prior to enrollment– a health history form and a copy of a current physical signed by a physician. Students without these two forms will not be admitted to the program. Please forward health forms to: VTS 6353 Germantown Ave, 3rd Floor Philadelphia, PA 19144 Questions? Call (267) 331-8735 or Email [email protected]

Home : Work : Cell:

Home: Work: Cell:

First Name , Last Name, Home Phone, Work Phone, Cell Phone, Email, Relation

First Name , Last Name, Home Phone, Work Phone, Cell Phone, Email, Relation to child,

Policy Number, Name of Health Insurance Provider, Primary Physician, Address, Phone, Hospital, Preference,

yes 1 no 2 If yes, explain:

yes 1 no. 2 If yes, explain:

yes 1 no 2 If yes, explain:

By typing your initials below it acts as your consent. Parent’s/Guardian’s Initials ____________

By typing your intials below it acts as consent. Parent’s/Guardian’s Initials ____________

I hereby give permission for my child to be photographed during VTS S.T.E.M Summer Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of VTS By typing your initials below it gives consent. Parent’s/Guardian’s Initials ____________

I hereby give permission for the transportation of my child for official VTS activities by modes of transportation agreed to by the program organizers. By typing your name initials it acts as your consent. Parent’s/Guardian’s Initials ____________

VTS is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that payment is non-refundable, however if my child is enrolled in S.T.E.M Summer Camp will attend unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). Guardian Signature:_ Printed Name of Parent/Guardian: by typing your name you allow it to acts as your signature

Student’s Name, Date of Birth , Grade entering in Fall 2020 , Gender ⧠ Male ⧠ Female, T-Shirt Size , Address: City: State: Zip Code: The following information is requested to help our teachers/staff/volunteers get to know a little bit about your child before he/she starts his/her session. The information will be kept confidential and is only shared with VTS staff who will be working directly with your child. Please be thorough in order to help us provide your child with the best experience possible. 1. Does the student go by a nickname? 2. Does the student have an unusual fear of the dark, thunderstorms, woods or other items the organization 3. Does the student experience any of the following?behavioral challenges ⧠ learning challenges ⧠ IEP ⧠ ADHD/ADD 4. Are there any recent events that may impact the student’s energy when away from home?⧠ Yes ⧠ No 5. Is there anything else you could tell us about the student that would be helpful for their teachers and/or staff to know? ⧠ Yes ⧠ No