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Sibling Information


Parent Information


Pickup Authorization


Medical & Emergency Contact Information


Liability Release

  • I am the parent or legal guardian of the student listed above. I give permission for the student to participate in all activities led by STEm Cafe Tech staff. I give STEM Cafe Tech permission to monitor the administration of prescribed medications, provide routine healthcare, and seek emergency medical treatment, including ordering of x-rays or routine tests, as determined necessary by a medical professional. Additionally, I give permission to the emergency medical personnel to secure and administer treatment including emergency medical or surgical treatment and hospitalization, if necessary. In these cases, STEM Cafe Tech will make every effort to contact the parent/guardian immediately, and notify them regarding any required care, however care will not be denied or delayed for lack of parental/guardian contact or consent, as this release provides that. I hereby waive and release STEM Cafe Tech, its owners, agents, partners, facility providers, and employees from liability for any injury or illness incurred while at STEM Cafe Tech, resulting from ordinary activities. I agree that there is risk of injury to the participant as a result of certain activities, and knowingly and voluntarily assume all risk of such injury. However, I agree that I am not releasing STEM Cafe Tech, its owners, agents, partners, facility providers, and employees from gross negligence, reckless conduct or intentionally tortuous conduct. To the extent this release conflicts with state law governing releases, this release is to be given the fullest force and effect permitted under state or provincial law.

    Physician’s Information: All participants/attendees must provide STEM Cafe Tech with a primary care physician’s name and contact information on the student information form. All parents/guardians are required to provide the medical insurance carrier and the policy number of the participant. If the participant is not covered under a health insurance plan, or if you do not wish to provide STEM Cafe Tech with your medical insurance information, you agree to accept all financial liability should your child require medical care while attending STEM Cafe Tech, and release and indemnify STEM Cafe Tech from any and all financial responsibilities.

    Please print your name below to agree with the above listed statements.


Physical Activities & Field Trips

  • Please indicate your preference for physical activities and field trip.