Registration form
Starting a Mad Science After-School Science Club is easy…
1) Fax this form to Mad Science at 910-458-4763 – or call us with your information at 910-458-4740.
2) Provide space for your Science Club. Classrooms in grades 3 - 5 are preferred.
3) Schedule your free Mad Science assembly.
4) Send the registration forms home with your students – we provide the forms!
It’s that simple!
We can handle all registrations, payment processing and other program details or we work with your established system. See enclosed Frequently Asked Questions for program options. Science Clubs are available any day of the week and can start at any time of the year. There is no obligation or cost to your organization. If enrollment does not meet the minimum (15 students), we cancel the class. We will create and provide the class rosters before the first class so you can let your teachers know which students are participating in the Mad Science After-School Science Club.
Yes! We want an after-school Science Club at our school! Fax form to 910-458-4763.
School Name: ________________________________________
Contact Name(s): __________________________________________________________________
Daytime Phone(s): _________________________
Alt. Phone(s) or Cell _______________________
Dismissal Time: __________ School Enrollment: _____________ After-Care Program: Y N
Start date (week of…) ___________
End Date (week of…) ___________ # of Weeks ____________
Day(s) of class:
Indicate preference with 1 – 3, (most to least desired). “X” days that are not available. Use each number more than once if multiple classes/days are available. For maximum flexibility for your students choose two consecutive days. Mad Science offers classes that are age and grade appropriate. If numbers permit, classes will be split into K-2 and 3-5.
Monday ________ Tuesday ________ Wednesday ________
Thursday ________ Friday ________
Dates with no class/School breaks: ________________________________________________________________
Requested Date/Time of Free School Assembly (ies): ______________________________________
Dates may be subject to instructor availability so respond early to confirm your registration.
Completion of this form does not guarantee acceptance nor obligate Mad Science in any way.
See attached FAQ’s for additional information concerning scheduling and class confirmation.
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