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
One registration form per participant
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
____White or Caucasian
____Native Hawaiian or other Pacific Islander
How did you hear about us? ____Email
Significant Health/Other Concerns (Allergies to food or drugs, chronic conditions, medications, behavior or emotional concerns) __________________________________________________________________________________________________ __________________________________________________________________________________________________ Release My signature indicates that I support my childâ€™s full participation in the IMSA Rock Island Field Office program and give permission for my childâ€™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.
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.