STEAM After-School Registration

Registration Information
Student Name
First Last
School:
Grade:
Please enter a number from 3 to 8.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian Name
First Last
Parent/Guardian Phone
Parent/Guardian Email
Program Options
LEGO Powered Machines: Grades 3-5

TYNKER Coding: Grades 3-5, Grades 6-8

LEGO SPIKE Prime Robotics: Grades 6-8

Virtual Reality Explorers: Grades 6-8
Program Selection:*
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Photo/Media Ownership Release Agreement
I understand that the photographic image(s), video(s), and/or audio recording(s), in which I am a participant/subject, is(are) being produced and owned by Mosaic Life Care Foundation. I hereby acknowledge that my participation may be edited and used in whole or in part as desired in any way by the Foundation including, but not limited to, being reproduced, duplicated, and used for non-theatrical audiovisual informational, public relations, fund development, and general education purposes. I also consent to the use of my likeness and voice for all purposes listed above in connection with the images and audiovisuals through traditional print, radio, television and/or online media platforms for an indefinite period of time.
CONSENT OF PARENT OR GUARDIAN
I agree to this media ownership release.
I hereby certify that I am the parent/guardian and do hereby give my consent without reservation to the foregoing on behalf of this participant.
CAPTCHA

After-School Programming Registration

Registration Information

Program Options

Photo/Media Ownership Release Agreement

Main office

Forms

Newsletter

Resources