Parent Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DCSMI Participant's (Your Child's) Name *

First Name

Last Name

Grade Student is Entering in Fall 2025 *

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Student Gender

Male

Female

Non-binary

I prefer not to disclose

Has your child participated in DCSMI programs in the past? *

Yes

No

How did you hear about these summer math enrichment workshops? *

Word of mouth via another parent or student

Neighborhood listserv. WhatsApp group, group text chain, etc

Email from teacher, school official

Internet search

None of the above

Health Agreement - If you agree with the policies outlined below, please check the I Agree box below, and write the current date in the field provided *

As a parent, I acknowledge that DC Summer Math Institute, Inc. (DCSMI) is not responsible for any medical care for my child if that becomes necessary over the course of the workshop, since there is no nurse on location. I am aware that if my child were to experience a health emergency, illness or ailment during the workshop, I would be contacted immediately via the cell provided on this form, and I would be expected to come immediately to the location to pick up my child. I agree to not send in any snacks with my chlld to the workshops, since those might cause allergic reactions in other participants.

I Agree to the policies outlined above, on this date:

Parent Agreement - If you agree with the policies outlined below, please check the I Agree box below, and write the current date in the field provided *

As a parent, I acknowledge that DC Summer Math Institute, Inc. (DCSMI) is only responsible for the instruction and supervision of my child (named above) between the hours of 3 pm - 4:30 pm when he or she is attending the workshop. I understand that my child will not be allowed at the UP Robotics facilities before the 3 pm start time (unless he or she is attending a Robotics day camp there) or after 4:30 pm once the daily session ends. If DCSMI determines, in its sole and exclusive discretion, that my child’s behavior disrupts or negatively impacts the experience of other DCSMI participants, and/or if he or she does not comply with the reasonable behavioral guidelines , he or she may be asked to leave DCSMI, with no refund. I understand that the payment for workshop is absolutely and unequivocally non-refundable, even in the case of family emergencies. I also understand that, if I use Venmo or PayPal instead of Zelle, I will be responsible for avoiding payment transaction fees by choosing the Payment between Friends option on Venmo or PayPal (NOT the Goods and Services option), and that in the event that fees are incurred accidentally, I will have to cover the payment of those fees.

I Agree to the policies outlined above, on this date:

Date of Electronic Signature *

MM

DD

YYYY