Science Center of Pinellas County

In case of emergency, please provide us with the name and telephone number of a person other than the parent. Please note that parents will be contacted first (unless otherwise noted) and the emergency contact will only be used as the last resort.

Waivers & Liability

Television/Newspaper/Staff photographers photograph our students enjoying our activities. Do you give permission to have your child photographed by the media?

You must read and agree to the following before continuing:
I agree to indemnify and hold harmless the Science Center from and against all liability or loss that the Science Center may sustain as a result of claims, demands, actions, liability, costs, attorney's fees, or judgments arising or resulting from the student participating in Science Center activities. YES

I have read the above medical, media, and hold harmless/indemnify information and give my permission for the above named child to participate in Science Center activities and/or field trips associated with classes. I give my assurance that this information is correct and will notify the Science Center of any changes. YES

Program Selection

Payment Information

To take advantage of special member prices, sign up or renew your membership now. The amount due for membership will be added to the program fee entered above upon checkout. If you are already a member, simply skip this section to Complete Registration Payment.

Student's Name*	Male Female
Address, including City, Zip*
Home Phone*	Parent or Contact Email*
Student's Birthdate (MM-DD-YYYY)*	Age*	Grade*
School

Father's Information	Mother's Information
Father's Name	Mother's Name
Occupation	Occupation
Employer	Employer
Work Phone	Work Phone
Cell Phone	Cell Phone

Name*	Relationship to Student*
Home Phone*	Work Phone	Cell Phone

Your full name:*
Program cost:* $	Today's Date*
Give online to the Science Center wth your Program Registration! Additional donation amount (will be added to your total): $

Science Center of Pinellas County

Register Online Now!

Student Information
(* = required)

Parent Information

Emergency Contact Information

Waivers & Liability

Program Selection

Payment Information

Science Center of Pinellas County

Register Online Now!

Student Information (* = required)

Parent Information

Emergency Contact Information

Waivers & Liability

Program Selection

Payment Information

Student Information
(* = required)