Science Nights On-line Application

A * denotes a required field

* Student First Name:
* Student Last Name:
* Student Email Address:
* Student Grade or Class:
* School Currently Attending:
	(Other, if not listed above)

* Parent/Guardian First Name:
* Parent/Guardian Last Name:
* Parent/Guardian Email:

* Address:
Address2:
* City, State, Zip:	,
* Your County:
	(Other, if not listed above)

Home Phone:
Cell Phone:

Any Accessibility Needs: (such as mobility, allergies, visual or hearing impairments, etc.)

* Sessions: Please indicate which session(s) you are interested in attending Tuesday, October 9^th – Chemistry Tuesday, November 13^th – Physics/Engineering Tuesday, December 4^th – Earth/Atmospheric Science Tuesday, February 5^th – Math/Computer Science

I, the undersigned, the Parent /Lawful Guardian of the student named above, hereby acknowledge that as a condition of the Student participating in the activity, agree to hold harmless Salisbury University, its employees and volunteers, its governing board, the individual members thereof, and all other system officers, agents and employees from any liability, lawsuit, cost, expense or claim of any type whatsoever (including legal fees) for any harm, injury or death arising out of the above mentioned activity. * Parent/Guardian Signature:

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