Delaware Teen Science Café information form Registration for the Delaware Teen Science Café is not finalized until this form is completed by a parent or guardian. DTSC Information Form Parent or Guardian Name * Parent or Guardian Name First First Last Last Parent or Guardian’s Email * Parent or Guardian’s Phone Number: * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Emergency Contact during the event * Emergency Contact during the event First First Last Last Emergency Contact’s Phone Number * Attendee information Attendee’s Name * Attendee's Name First First Last Last Attendee’s age * Attendee’s Grade Level * Attendee’s School * Attendee’s Email Add Remove I am the parent/legal guardian of the attendee named above. I have read and understood the below statement regarding the videotaping and/or photographing for the Delaware Museum of Natural History and the Teen Science Café Network. * I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, audio recordings, or video tapes of the child/children named above. I also grant the Delaware Museum of Nature and Science and the Teen Science Café Network the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the Delaware Museum of Nature and Science and their agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. I do not give permission to video, audio record, or photograph my child/children. If you are human, leave this field blank. Submit
