YES! Youth Engaged in Science

Birthday Party Registration

This form will be used to notify our Party Coordinator of your interest in having a YES! Youth Engaged in Science Robotics Themed Birthday Party! Once our Party Coordinator receives your information, she will contact you and work out the details of your party with you. Once you and the Party Coordinator have agreed on the details and we have received your $50 deposit, your party will be confirmed with an email notification showing all of the details for your party.

Child First Name:
Child Last Name:
Age Child is Turning:
Parent/Guardian First Name:
Parent/Guardian Last Name:
Day Phone Number:	-
Cell Phone Number:	-
Parent/Guardian Email:

Home Address:
Line 2:
City:
State:
Zip Code:

Party Address (If Different):
Line 2:
City:
State:
Zip Code:

Requested Day and Time:
How did you hear about us:

Note: The above date is a requested date only. The actual date and time of your party will be scheduled with our Party Coordinator based on availability. Please do not make any commitments based on this date before speaking with the Party Coordinator.

Photo/Video Release:

With your permission, during this program, your child may be photographed for photo displays at our schools and learning centers, for the YES! Youth Engaged in Science website and/or advertisements, in order to promote the YES! Enrichment Programs. Please check the appropriate box below granting or denying permission for these films to be publicized. This blanket release applies only to positive, non-controversial stories and information.

By Checking:

	YES: I give permission for my child to interviewed, photographed and/ or videotaped for publicity purposes. These pictures may be put on the YES! web site or flyers.
	NO: I do not want my child interviewed, photographed and/or videotaped for any publicity purposes, INCLUDING INTERNET USAGE

Please enter the following words exactly as they appear:

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