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Student Intake

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Student Intake

First Step: Student Intake Form

Thank you for contributing a bright and intrepid new student to our imaginative and creative world of Atomic Adventures! We are so glad to have you!

Please take a moment to fill out our Student Intake Form below. Forms must be filled out completely and received by us at least 72 hours prior to your student’s first day of class.

Parent or Guardian Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone(Required)

I am registering multiple students(Required)

Yes

List

Students Full Name

Students Birth Date

Gender

Allergies

T-shirt Size (S, M, L, XL)

Click the (+) on the right to add additional students

Child's Name(Required)

First Last

Child's Birth Date(Required)

MM slash DD slash YYYY

Students Gender(Required)

Male

Femal

Would rather not say

Which week will your child be attending

6/20 – 6/24

7/5 – 7/8

7/11 –7/15

Subject to availability

Does the student have any allergies?(Required)

Yes

Known Allergies

To add multiple items use the (+) symbol to the right.

Emergency Contact (Primary)(Required)

First Last

Phone

Emergency Contact (Secondary)(Required)

First Last

Phone

I authorize the following people to drop off or pick up my child(Required)

Name

Phone

Please confirm your child's t-shirt size(Required)

Small

Medium

Large

X-Large

Tablet or laptops are required to participate in activities(Required)

My student will bring their own tablet or laptop

My student does not have a tablet or laptop

Note: If you do not own a tablet or laptop we have loaners available.

Upon registration you agree that Atomic Adventures, LLC., has permission to use the student's photographsin all of its publications for marketing and promotion without payment or other consideration.

I agree to photo release terms(Required)

Yes

Signature(Required)

Date Signed(Required)

MM slash DD slash YYYY

Seating is based on availability and class sizes are limited. To ensure your student(s) seat is available both intake form and payment must be received. Seats are available on a first-come-first-served basis.

Atomic Adventures is a Summer STEAM program designed to engage students with the disciplines of Science, Technology, Engineering, Arts and Technology.

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