Program Registration Form

 

Fill out all the fields below and hit the "Submit" button. Then mail in payment in full to:

Mad Science of Hawaii
98-138 Hila Place, #10
Pearl City, HI 96782

Please fill out one form for EACH child. Completing this form does not guarantee your child a spot in the ASP you are requesting. Space is not guaranteed until payment has been received in full!

 

Child's Name:
Child's Birthday:

Child's Grade:
Health Concerns:
School/Location:
Is your child a student at this school?
Class Start Date:
Parent/Guardian Name:
Email:
Home Phone#:
Cell Phone#:
Mailing Address:
City/Zip:
Pickup Option:

My child will be picked up after class (child must be picked up & signed out at the classroom door in which the program is taking place.)

My child will attend after-school care (all A+ children will be escorted back to class by the instructor.)

My child will travel home by his/her own means (Children are free to leave unsupervised after class. If you wish to pick up your child at any location other than the classroom in which the program is taking place, you must choose this option.)

If picking up, please list ALL person/s authorized to pick up your child:
Would you like to be a Parent Volunteer?

Yes     No

As a Parent Volunteers you attend every class to assist the Instructor in collecting children before/after class and assist children in their activities. A full registration refund is given at the conclusion of the program as our thank you. If you are chosen to be the Parent Volunteer you will be contacted by our office prior to the start of the program.

Payment Option:

 Check (mail to: Mad Science at address listed above)

 Credit Card (2% fee added due to additional credit card processing fees. Please call Mad Science office at 737-2400 to process payment)

Newsletter:   

Would you like to receive our Mad Science Newsletter for coupon/special offers, fun science facts, and updates on upcoming programs?

Yes    

Thank you for enrolling in our After School Program! An email will be sent to you to confirm your registration once we have received your payment in full.