Name of Child *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent or Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian Cell Phone *

(###)

###

####

Parent or Guardian Home Phone *

(###)

###

####

Name of Emergency Contact *

First Name

Last Name

Emergency Contact Cell Phone *

(###)

###

####

Photo Release Consent *

I give consent for photos of my child to be taken at EYE Saturday Program to be used in the promotion of further engineering programs.

Yes, I give permission

No, I do not give permission

Financial Assistance *

If paying for EYE is a hardship, please check the appropriate box below, and we will waive the entrance fee.

Yes, for my child to participate, financial assistance is necessary.

No, financial assistance is not necessary.