Biosphere 2 2014 Science Academy Registration Form Question Title * 1. Student Participant Information Last Name: First Name: Age: Date of Birth: Gender: Nickname (or what student prefers to be called): SCHOOL NAME, City and State (Spring 2014): SCHOOL NAME, City and State (Fall 2014): Grade in Fall 2014: Home Address: City: State: Zipcode: Email Address: Question Title * 2. DISABILITY / LIMITATION INFORMATION (Please advise of any disabilities/concerns that we should be aware of) Question Title * 3. PARENT / GUARDIAN INFORMATION Parent/Guardian 1: Last Name First Name: Primary Phone Number: Secondary Phone Number: e-mail Address: Parent/Guardian 2: Last Name First Name: Primary Phone Number: Secondary Phone Number: e-mail Address: Question Title * 4. BIOSPHERE 2 SCIENCE ACADEMY WEEK SELECTION (check one) July 6-12, 2014 (for 6-9th grade students) July 13-19, 2014 (for 9-12th grade students) Question Title * 5. DEPOSIT / PAYMENT INFORMATION Credit Card: Contact Nancy Boklund at (520) 838-6192 Checks: payable to U of A, Biosphere 2 (please write student's name and "Science Academy" on memo line). Mail To: Biosphere 2 Science Academy, Attn: Nancy Boklund, P.O. Box 8746 Tucson, AZ 85738 Question Title * 6. UPON ARRIVAL, STUDENTS WILL RECEIVEa Biosphere 2 t-shirt, hat, water bottle, and notebook.Please indicate the shirt size needed (in men's sizes). Small Medium Large X-Large 2X-Large Other Size (please specify) Question Title * 7. DROP-OFF and PICK-UP AUTHORIZATIONPlease only provide names of those, other than parents/guardians listed above, who are authorized to pick up your student. IDENTIFICATION WILL BE REQUIRED. Authorized Person 1: (first and last name, phone number) Authorized Person 2: (first and last name, phone number) Question Title * 8. CHECK-IN and CHECK-OUT:Sunday Student Check-in: Noon - 3PMSaturday Student Symposium: 10AM, FAMILIES ARE WELCOME!Saturday Student Check-out: Noon - 2PM Please indicate if you would like Biosphere 2 to provide student transportation TO and/or FROM the Tucson International Airport ($25 each way per student). We will follow up regarding details. Question Title * 9. EXPECTATIONS: Please describe briefly your expectations of the B2 Science Academy Question Title * 10. ADDITIONAL INFORMATION THAT YOU MAY WANT TO SHARE: Question Title * 11. How did you hear about the Biosphere 2 Science Academy? Biosphere 2 Website Social Media School or Teacher Biosphere 2 Visit Print Media Other (please specify) Your voluntary, electronic submission of these forms serves as your signature in place of a traditionally signed paper form. By submitting payment and completing the forms online you are authorizing that the information provided is correct and that you are intending to register your student in the 2014 Biosphere 2 Science Academy. Done