Email *
Referral Code, Representative Name or Organization Name (school, association, group) *
Student Preferred Name
Student Grade (at time of registration ) *
Student Age (at time of registration ) *
School Name *
Phone Number (Primary Residence) *
Phone Number (Secondary Residence)
Language Spoken at Home *
Student's Mother / Father / Guardian Home Phone *
Student's Mother / Father / Guardian Email *
Student's Mother / Father / Guardian Cell Phone
Primary Caregiver's Phone Number
Non-Custodial Parent Phone
Special Instructions / Additional Information
Relationship to Child
Phone
Cell Phone
Relationship to Child
Phone
Cell Phone
Relationship to Child *
Phone
Cell Phone *
Relationship to Child
Phone
Cell Phone
Printed Parent/Guardian's Name: *
Printed Parent/Guardian's Name: *
If yes, please explain and detail routines, medications, adaptations etc.
Other instructions regarding 1-1 support.
If yes, please explain with details
Other instructions regarding the puffer/inhaler use?
Medical-Alert Bracelet for what purpose?
If at risk of anaphylaxis, explain why.
Epi-pen for what purpose?
Please specify other:
Please explain reaction observed?
If other, please specify:
Is there anything else about your child’s medical history we should know about? (if none indicate no) *
Please Explain Requirements:
Please Explain Requirements:
Parent/Guardian's Signature *
Parent or Guardian Print
If you have chosen a double room, do you have a roommate request? (Taken into consideration but not guaranteed, and must be a mutual request)
Payment confirmation number: *
Name of Student *
*By submitting the form, I confirm that I have made payment according to my payment option choice. (Partial or Full Payment) *
PLEASE SIGN IN THE SIGNATURE BOX FOR ACKNOWLEDGEMENT AND ACCEPTANCE OF THE ASSUMPTION OF RISK AND INDEMNIFYING RELEASE *
ASSUMPTION OF RISK AND INDEMNIFYING RELEASE
While STEM CANADA staff and instructors will make every reasonable effort to minimize exposure to known risks associated with each Registrant’s participation in a STEM CANADA program , I hereby acknowledge that I and/or my child if I am registering on his/her behalf (collectively, the “Registrant”) may be required, depending on the nature of the Program, to participate in various physical activities that may involve risk of injury. In this regard, I agree that I have provided (if required) a complete and accurate health history and hereby permit the Registrant to participate in the full range of Program activities, except as specifically noted by me in the health information section of the Program registration (where applicable).
I, the undersigned, as a participant or as a parent/guardian of a participant in a STEM CANADA program, hereby understand and accept that participation in a pre-university program taking place on a publicly accessible university campus by persons 18 years of age and older and who are not associated with the program involves certain inherent risks. These risks include, but are not limited to, unwanted contact, abuse, personal harm, verbal distress, physical injury, emotional distress, and/or property damage.
In consideration for the Registrant’s opportunity to participate in a STEM CANADA program, the receipt and sufficiency of which is hereby acknowledged, I hereby release and forever discharge STEM CANADA / Canadian Institute of STEM Innovation, its partners, all staff members, stakeholders, its respective officers, directors, employees, volunteers and agents, and their respective successors and assigns from any and all liability for damages sustained in consequence of loss, injury or damage to the Registrant, and from all other actions, causes of action, claims, demands or damages of any kind with respect to death, injury, loss or damages to any person or property arising out of or connected with preparation for, or participation in, the Program.
To the fullest extent permitted by law, I hereby release, indemnify, and hold harmless STEM CANADA / Canadian Institute of STEM Innovation, its partners, all staff members, stakeholders, its respective officers, directors, employees, volunteers and agents, and their respective successors and assigns from any and all claims, demands, suits, costs, expenses, liabilities, and damages (including attorney’s fees) arising out of or in connection with any injury, illness, death, loss, or damage to person or property which I or my child(ren) may suffer or incur as a result of, or in connection with participation in the program.
I confirm that I have read and understood this Assumption of Risk and Indemnification Release before signing it and I am aware that by signing it, I am waiving certain legal rights which I or my heirs, next of kin, executors, administrators and assigns may have against The Canadian Institute of STEM Innovation, its partners, all staff members, stakeholders, its respective officers, directors, employees, volunteers and agents, and their respective successors and assigns.
View assumption of risk and indemnifying release here
1. By paying for and submitting a deposit and / or the PROGRAM REGISTRATION FEE, it is understood that this becomes a binding commitment for the program. This fee is non-refundable whether or not your child attends the program. There are no exceptions to this policy.
2. PROGRAM REGISTRATION FEES cannot be used towards any other program registrations and are non-transferable from program to program, nor from student to student unless written permission is granted or a program credit is issued and the reasoning is within the guidelines of this program.
3. All fees paid are NON-REFUNDABLE under any circumstances. This no refund policy includes donations raised, application fees, program fees, and program deposits.
4. If a student is away from the program or for a day from any program activities due to family travel, illness, or another purpose, program payments will not be refunded, nor pro-rated. No exceptions to this policy will be granted, however a program credit is available.
5. In the event a student is subject to involuntary or voluntary withdrawal while attending the program, is suspended, expelled, or otherwise required to leave the program for any reason, all fees paid to the program are strictly non-refundable and will be forfeited.
6. Any program scholarships cannot be combined with any other discounted offers.
7. An NSF fee of $50 will be applied to all automatic debits processed with insufficient funds. This NSF MUST be paid within five (5) business days of the NSF notice. The ORGANIZERS reserves the right to suspend attendance to students with delinquent accounts or program fees not paid in full prior to the commencement of the program.
8. Program credits are not applicable and will NOT be granted if the registrant chooses to withdraw for any reason.
9. In the event that a student is ineligible or unable to attend the program for any reason including illness, any fees paid or raised through the fundraising pages will be issued as a credit only.
10. Any program fees will not be prorated during short program weeks.
11. In the event in-person classes need to move online or cancelled for any reason including a natural disaster, closure due to public health mandates, a pandemic, or mandated closure of our facilities, program fees not be refunded but only a portion of the fees paid, or raised will be issued as a program credit. There are no exceptions to this policy.
By signing this declaration I acknowledge that:
– All fees paid are non-refundable.
– I am responsible for paying the posted registration fee of $59 to complete the application process in addition to a $250 deposit or the program fees paid in full.
– I understand that if I opt to pay the program fees in full before July 10, 2024, that the application fee will be waived.
– I understand that all fees paid are non-refundable.
– I understand that if my family goes on vacation or is away, that program payments are still due and will not be deferred.
– I am aware of the cancellation policies and agree not to dispute or attempt to chargeback the required charges.
– I am aware that if I fail to pay the program fees in full, that any previous monies paid will be forfeited.
– I acknowledge that my child must be enrolled in the level that corresponds with their age group.
– I acknowledge that my behaviour and my child’s behaviour are to remain respectful at all times. Any ill behaviour exhibited by myself as the parent/guardian and/or my child will jeopardize their placement in the program and may result in my child being removed from the program without further consideration for re-admission and that no refunds will be granted.
– I acknowledge that I am aware that this program carries risk. I have read and understood the contents of the indemnifying release.
– I understand that this program is taking place on a University Campus and that there will be many adults over the age of 18 present on Campus at random. I am declaring to assume all risk associated with this scenario.
– I understand that some of the facilitators are from post-secondary institutions, or from STEM-based corporations world-wide, and that they may not hold a vulnerable sector police clearance check in Canada, nor in their region. I am declaring to assume all risk associated with this.
– I confirm that I have reviewed and signed the Assumption of Risk Waiver and Release Form.
Parent or Guardian Print
Referral / Source
Thank you for your inquiry. Is there anything else you would like to mention?
Parent or Guardian Print *
