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Girls Engineering Registration Form

This program is being funded in part by Avista Corporation.  Refunds will be issued if canceled at least two weeks prior, minus a $25 processing fee.  No refunds if canceled less than two weeks before the first class. 

Questions? Call 541-482-6767 ext 226 or email skoshi@scienceworksmuseum.org.

 
* Student First Name 
* Student Last Name 
* Date of Birth 
* Grade 
* Parent/Guardian Name 
* Home Phone 
* Cell Phone 
* School 
* Work Phone 
Parent/Guardian Name 
Home Phone 
Cell Phone 
Work Phone 
* Mailing Address 
* City 
* State 
* Zip Code 
Email 
* Member?Yes No 
* Emergency Contact Name (different than guardians listed above) 
* Emergency Contact Phone 
* Physician Name 
* Physician Phone 
* Important Information (allergies, medical, emotional or special needs). This information will be kept confidential. Please list all information, no matter how minor. It is important that our teachers and staff know of any concerns in order to handle possible situations with ease.  
* I authorize ScienceWorks to photograph and/or videotape my child for publicity purposes (including visits from news media and photos on our website). ScienceWorks will not release any personal information regarding my child other than her first name and age. I understand that these materials will be the property of ScienceWorks, not to be sold or loaned, and will be used only to promote ScienceWorks education programs.
Yes No 
* Class ChoiceGECOS Jr. Spring Program (Thursdays for grades 4 & 5)
GECOS Spring Program (Wednesdays for grades 6 - 8)
* Have you participated in a previous GECOS program at ScienceWorks?Yes No 
* The following question is for granting purposes: Please check the box that most closely describes the participant's ethnicity.American Indian or Alaskan Native
Asian
Black/African-American
Caucasian/European American
Hawaiian or Pacific Islander
Hispanic/Latino
Multi-racial
Other
 

Thank you for submitting your registration request.   Once payment has been processed you will receive a confirmation.

 
 
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