APPLICATION FORM

							VERINZA
CENTER for MATHEMATICS & SCIENCE


                                             APPLICATION FORM

A. Student & Parent Information

Student Name:___________________ ____ _____________________________
                  First                     M.I      Last

Date of Birth: ________________________

Mother/Guardian:___________________ ____ __________________________________________
Father/Guardian:___________________ ____ __________________________________________

Address: _________________________________________________________________________

City: ________________________ State:             WA        . Zip:_____________

Phone Number:___________________ ______________________ _____________________
                          Work                       Home                     Cell

Email Address: ________________________________________




B. Emergency Contact Information (Required):

Name:________________________________________________ Relationship to Student: _______________

Phone Number:_________________

Note: This person must be accessible for contact during the time the student is on the premises.

Please list below any instructions that need to be followed in case of emergency:




Please provide:

   a recent photograph of the child and the parent (group or separate)
   a photocopy of the driver's license or picture ID of the person designated to pick up the child after class. The
    child will not be released into the custody of anyone who is not so designated and whose ID does not match
    with the ones on file. Please include both parent's IDs if either may pick up the child.
   a recent photograph of the person to contact in case of emergency (specified above).


C. Sections Interested (check all that apply):

    Subject:                    Math            Science


    Level                       Beginner        Intermediate                      Advanced      Pre-College

    An interview and an aptitude test administered by the Center are required as part of the admission process.
VERINZA
CENTER for MATHEMATICS & SCIENCE

D. Student's Background in Science & Math:

Describe student's background skills & knowledge in Math & Science. Include any information, evaluations or test
reports which would be helpful to us in evaluating the student. Continue on additional sheets if needed.




E. Additional Information:

Include below any other relevant information (e.g dietary restrictions):




F. Agreement:

I have read the rules and regulations governing the instruction and agree to adhere to these rules & regulations.

__________________________           _______________________________              ____________________
Name of Parent                            Signature                               Date



Mail the completed application form to Verinza Center for Mathematics and Science, c/o Dr. Mohan
Venkataramana, 17415 NE 28 St, Redmond WA 98052. Please contact (425) 883-0664 or send email to
admissions@verinza.org after mailing your application.
VERINZA
CENTER for MATHEMATICS & SCIENCE

                                           RULES & REGULATIONS


1. After admission to the Verinza program, the student will be eligible to register for the courses as and when they
   are offered. A listing of current courses will be available on the Verinza website (www.verinza.org), or by
   contacting us by email/phone. From time to time we will also inform you of any courses that we feel would be
   appropriate for your child.

2. Registration in any given course is subject to approval by the director of the Verinza Center.

3. Tuition fees and any activity fees are due by the first day of classes. 90% of the tuition fees are refundable
   before the first day of classes. Tuition fees are not refundable after the first day of classes. Activity fees are not
   refundable. Fees will not be prorated for any reason.

4. Other costs you might incur will be for books and support materials such as calculators etc.

5. The class timings will be specified before the first day of classes. Please make sure students are in the
   classroom or at the designated place at least 5 minutes ahead of the start time. The classes end at the time
   designated. Parents or designated persons must pick up the child within 10 minutes of the end of class. Due to
   space limitations, the Center is unable to provide facilities to wait for a long time for a parent to pick up the
   child. Please pick up your child at the designated pickup area.

6. Children and accompanying adults must follow the rules and regulations specified by the Center. The Verinza
   Center for Mathematics & Science is not responsible for any unsupervised activities of the child. The parent
   enrolling the student will be responsible for any third party damages incurred because of the activities of the
   child. Please instruct your child about the safety procedures.

7. Additional rules (such as safety rules) are applicable to laboratory projects and special activities. Students will
   be instructed at the appropriate times.

8. Enrolling parent agrees that his/her health & accident insurance covers all the costs for the child during the
   instruction, and agrees to defend and hold the Verinza Center for Mathematics & Science harmless in the case
   of any damages or lawsuits related to the program. The Verinza Center's maximum liability is limited only to
   repayment of the tuition fees under any circumstance and is subject to the refund policy described below.

9. The Center may reorganize or merge sections or timings as deemed appropriate by the instructor.