Registration

Student Information

First Name: Last Name: Date of Birth: Grade Level: Select Grade Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Other GPA (optional): School Name: Home Address: Parent/Guardian First Name: Parent/Guardian Last Name: Parent/Guardian Contact Number: Parent/Guardian Email Address:

Emergency Contact Information

First Name: Last Name: Contact Number: Alternate Contact Number (optional):

Medical Information

Allergies (optional): Medical Conditions (optional): Medications (optional): Physician's First Name: Physician's Last Name: Physician's Contact Number:

Program Interest

Parental Consent

I, the undersigned, give permission for my child to attend enrichment classes in the Lexington Science Academy. I understand that all necessary precautions will be taken for the safety of my child. I understand that in case of an emergency, every effort will be made to contact me. If I cannot be reached, I give permission for the program staff to secure proper medical treatment for my child.

Parent/Guardian Initials:

Date:

Enrollment Agreement

By enrolling my child in the Lexington Science Academy, I acknowledge and agree to the following terms regarding appropriate behavior and conduct. I understand that if my child exhibits inappropriate behavior, including but not limited to the use of cell phones during classes, distracting other students, use of profanity, or any form of sexual harassment, they will be unenrolled from the program. In such cases, I will receive a prorated refund for the remaining classes. I commit to discussing these behavioral expectations with my child to ensure a positive and productive learning environment for all students.

Furthermore, I understand that Lexington Science Academy may use photographs or video footage of students taken during program activities for promotional purposes (e.g., website, brochures, social media) without compensation. Students will not be identified by name without separate specific consent. If I wish to opt out of this media usage, I will email contact@lexscience.org.

Video recordings of classes or setup for remote class participation may be available with advance notice.

Parent/Guardian Initials:

Date:

Lexington Science Academy Class Absence and Withdrawal Policy

Tuition at Lexington Science Academy is payable at enrollment. Refunds for withdrawal, minus the cost of any classes already attended, require one month's written notice. All classes are unique, and make-up sessions may not be available. If a student misses a class, a parent may request a make-up in a similar class, subject to the teacher's discretion and availability; however, no credit or refund is provided for missed lessons.

Parent/Guardian Initials:

Date:

Safety & Liability Responsibility Agreement

By enrolling in any class at Lexington Science Academy, I agree to have my child attend the class(es) and comply with Lexington Science Academy's rules and teachers' instructions, to take responsibility and pay for any damage caused by the child to the facilities. I will not hold Lexington Science Academy, its directors, teachers, staff, or teaching assistants liable for any accident, personal injury or personal property damage, illness, or other unexpected incidents, which may occur in the classrooms or when my child is enroute to the Lexington Science Academy.

Parent/Guardian Initials:

Date: