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FUNshop Registration Please return completed registration with payment to: IMSA Field Office FUNshop ATTN. Toni Petersen 1500 Sullivan Rd. Aurora, IL Fee per student-$20 Please Print

60506-1000

One registration form per participant

Student Name

Current Grade

Gender

Street Address

City

County

Home Phone

State

Cell/Emergency Phone

School Name

Zip Code

Email

School City

School State

Parent Name

Ethnicity (This information is requested so we may report statistical data regarding our participants to the State of Illinois and/or other program funders. Only aggregate data will be shared. Summaries will not contain individual information.) Select one of more from the following groups. ____American Indian or Alaskan Native

____Black or African American

____Asian

____Hispanic/Latino (a)

____White or Caucasian

____Native Hawaiian or other Pacific Islander

How did you hear about us? ____Email

____Web

____School

____Friend

_________________Other

Significant Health/Other Concerns (Allergies to food or drugs, chronic conditions, medications, behavior or emotional concerns) __________________________________________________________________________________________________ __________________________________________________________________________________________________ Release My signature indicates that I support my child’s full participation in the IMSA Rock Island Field Office program and give permission for my child’s photograph to be taken and full name to be used for educational purposes by IMSA. As parent/legal guardian of the above child, I do hereby fully release and discharge the Illinois Mathematics and Science Academy and the Martin Luther King Jr. Community Center, their officers, employees, and agents, from any and all claims which I or my child/ward may have arising out of injuries sustained by my child/ward as a result of his/her participation in the program.

__________________________________________________________________________________________________ Signature

Date

Payment Check payable to IMSA. No cash or credit card. A confirmation email will be sent to verify your registration. Payments for this program are not eligible for refunds.

Scholarships are available for qualified students.

Questions? Call Nicole Hoffman (309) 373-7795.


FUNshop Registration Form