Adventure Through Open Minds Science Club for Kids a.k.a A.T.O.M. Science Club for Kids
September 5, 2014
Dear ATOM Science Club Members and Families,
It’s almost time to begin another exciting year of ATOM Science Club for Kids. This Signup Packet contains all
the information you need to learn about and sign up for ATOM Science Club for Kids.
If you’re new and have not participated in club meetings before, start with “A Taste of ATOM Science Club”
(page 3) to get an idea of past activities and what to expect. Returning club members may want to start with
the “Club Activities” section (page 4).
To help you read through this packet, I have included a table of contents on the following page.
Scheduling club sessions can be challenging since I try to accommodate as many of you as I can. As you review
the proposed schedule (page 8), keep in mind that I can usually be flexible, not only in the open spots but
even within some of the planned times.
Please don't hesitate to contact me to work out any scheduling issues you may have.
As always, it’s great when returning club members can remain with their groups from the previous year. The
scheduling options are:



Stay with your group at the same time;
Choose a different time and group; or
Review the open slots on the schedule (page 9) and indicate whether one of them would work for
you. If there is enough interest in a particular day/time, I can create a new club.
I look forward to hearing from you as soon as possible about whether your child will return for another
exciting year. Please fill out and return the forms at the end of this information packet to let me know that you
plan to continue, and indicate the time slot(s) you or your group would prefer. If you can't choose a time right
now, just give me as much information as possible so I can develop a final schedule. See the signup details on
page 10 for full information on the process.
I look forward to resuming club meetings beginning the week of September 22, 2014. Please feel free to call
or e-mail me if you have any questions.
Warm Regards,
Leslie, a.k.a. "Madame ATOM"
650-271-2035 (cell)
P.S. I encourage you to share and pass along this packet to friends and classmates. I always appreciate
your referrals of new club members that keep us alive, vital, and growing. If you know of a group of kids (of
any age) who would like to start their own club, please contact me by phone or e-mail as soon as possible to
secure available time slots. And be sure to check out my Web site at www.atomscienceclub.com and pass it
along to friends and classmates!
1
Table of Contents
A Taste of ATOM Science Club ..........................................................................................................................................................3
Club Activities ..........................................................................................................................................................................................4
Including Parents During the End of Science Clubs ................................................................................................................5
Scheduled Field Trips ...........................................................................................................................................................................6
Planned Field Trips (not yet confirmed) ......................................................................................................................................6
Curriculum and Choices for 2014/2015 ......................................................................................................................................7
Tuition and Fees......................................................................................................................................................................................8
2014/2015 Schedule ............................................................................................................................................................................9
Signup Process ...................................................................................................................................................................................... 10
Club Day/Time Selection Form ..................................................................................................................................................... 11
2014-2015 REGISTRATION FORM .............................................................................................................................................. 12
RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT TERMS OF USE for 2014-2015 ............. 14
2
A Taste of ATOM Science Club
Weekly Meetings
Regular meetings give all club members a solid foundation in chemistry and physics. Any child between age 5
and 12 who is new to ATOM Science Club gets a grounding in the science of the atom and the basic forces that
govern our universe, starting with the very smallest units of matter. Returning club members build on the
foundation and add a focus on biology/neurology, geology/paleontology, astronomy, and robotics.
For advanced club members, my goal is to show that exploring a subject in depth requires integrating
knowledge from other fields. For example, to study Mars, we need to understand how to get there (rocketry),
how to dig below its surface (geology/paleontology) and how to determine what it means to be alive
(biology/neurology).
Weekly meetings combine hands-on activities, interactive discussions, and occasional special guests who
speak about the current topic.
Special Events, Field Trips, and Outings
Throughout the year, I plan a number of field trips and outings that help bring to life the topics we cover in
club meetings. Over the last few years, club members have participated adventures such as:
- Monterey Bay Aquarium Overnight Adventure
- CAL Day at UC Berkeley
- UC Berkeley Nuclear Engineering Department
- The Nike Missile Site at the Marin Headlands
- Model rocket launches at NASA
- Lab of Marian Diamond (researcher on Einstein’s brain)
- NASA's LCROSS Mission to the Moon Overnight
Adventure
… and many more
I offer two types of field trips:
1) Field trips offered by academic institutions or science centers that can guarantee a time and a day in
advance. These field trips may require an additional charge for the program and/or use of the facility.
2) Field trips to witness real science in action. These are more unpredictable because real scientific
activities (for example, viewing a rocket launch or making astronomical observations) can be affected by
weather, technical difficulties, and other factors that make them impossible to schedule for certain. You'll
need a sense of adventure and flexibility to get the most out of these field trips, which I hope to offer at no
additional cost.
Because I cannot be responsible for any children during times other than weekly club meetings, parents or
guardians must accompany children on field trips, which usually are scheduled during evenings or weekends.
Inside-the-Club Adventures
Following the success of our guests in previous years, I plan to invite more outside guests to club meetings to
share their specialized knowledge with club members. In the past, for example, a guest from UC Berkeley's
Nuclear Engineering Department spoke on quantum mechanics.
Outside-the-Club Adventures
I plan field trips to complement the topics we cover during weekly club meetings. These could literally be
outside adventures—e.g., viewing the moon through a telescope—or adventures at outside locations.
Summer Camp
Each year, I offer week-long summer camps beginning in June and continuing through August or early
September. Many of the topics are similar to what we cover during club meetings, but the week-long format
allows us to explore them in much greater detail. This summer, some camp sessions studied the human body,
focusing on the brain and other organs. Other camp sessions looked at how our bodies will react in outer
space. A special conclusion of the summer camps was an adventure to NASA Ames, where we toured the
model of the International Space Station to see what happened to frog eggs that were hatched in outer space.
3
Club Activities
Introductory clubs, as always, will focus on studying chemistry (the atom) and physics (movement).
Intermediate and advanced science clubs will explore the chemistry, physics, and math behind our
amazing universe through the study of what life is and how life exists on and possibly beyond our planet
earth. See the “Sample Biology Curriculum” (below on this page) for an idea about the kinds of topics we will
cover in clubs. More advanced clubs will be encouraged to pursue topics that most interest them.
We will use a variety of learning modes and tools to study real-world advanced research currently being done
to probe the tiniest living unit of life, the cell. Some of these will include:




Microscope studies.
Hands-on activities, such as building models of different living processes. These hands-on activities
will help club members touch and hold examples of what they’re learning so they can better
understand how organs, cells, and cellular organelles work together and communicate with one
another through chemistry, physics, shape, and size.
Viewing real footage or computer simulations of cells and how they manage their intra- and
extra-cellular functions.
Extracting DNA from strawberries and then making a necklace to hold the DNA strands. The
necklace is quite a conversation piece. Club members will be motivated to learn about how DNA
works so they can explain their DNA necklace to family and friends, which becomes an incredible
teaching tool.
SAMPLE BIOLOGY CURRICULUM
1) Define Biology
a) What is life.
b) Smallest functional unit = cell
i) Parts of a cell (for example: organelles,
DNA, cell membrane).
ii) Whole cell
2) Study the brain so we can study how cells work in one
organ of the body.
a) Study cells found in the brain (for example:
neurons, glial, Schwann cells).
b) Parts of the brain (for example: Prefrontal
Cortex, Neocortex, Temporal Lobe)
c) Study includes both: CNS (Central Nervous
system) and PNS (Peripheral Nervous System).
3) Study how our brains work consciously.
4) A Taking in information.
a) Study our 5 senses
b) Learn lobes in the brain that first get the
information.
5) B Processing the information = thinking
a) Past: memory (first the brain tries to identify
input from past experiences).
i) Study current research attempting to
understand how memory works.
ii) Learn ways to help your memory retain
information.
b) Present: then the brain communicates the
information between its parts.
c)
Future: Respond to information (output) and/or
store information (memory).
d) Understand why it is important to take time to
THINK before you respond.
6) Study how our brain controls our body without our
awareness.
a) Examples: Digestion, Circulation
b) Fight or Flight
7) Study our own brains.
a) What do we all have in common.
b) What is unique to each individual brain
including your own.
i) Learning styles.
ii) Difference between the left brain and right
brain.
c) If you don't use it, you lose it.
d) The effects of drugs and alcohol on your brain.
e) The importance things you must give your brain
to keep it healthy.
i) sleep
ii) water
iii) nutrition
iv) oxygen
8) When caring for your pet (cat, dog, hamster, fish)
consider it's brain.
9) Einstein's brain, was it different, did he have a
mutated brain due to his DNA?
10) Brain dissection (optional) for any science club
member, at the end of the year, after completion of
the above instruction.
4
Including Parents During the End of Science Clubs
An important aspect of being involved with cutting-edge science is working as part of a team. From private
and public companies to NASA and the International Space Station, the most successful organizations make
teamwork a huge part of how they work.
As they did last year, our weekly activities during club meetings will include learning how to work toward
scientific exploration and discovery as part of a team.
When teams work well together, not only is there enthusiasm and excitement, but the group often can
accomplish much more than an individual can alone. During club meetings, I will introduce the idea of what
makes for good teamwork, how individuals can contribute their own unique skills to the team, and how teams
resolve conflicts.
This year, we will work in teams to write and direct skits portraying concepts club members are learning.
This is an excellent way to reinforce their newly acquired knowledge. And it’s a great way for parents to see
what their children are learning—and to become engaged and involved in the learning adventure with ATOM
Science Club as they watch and applaud their children’s skits.
5
Scheduled Field Trips
As always, field trips will round out the science club experience by offering real-life, hands-on activities to
complement the learning that happens during club meetings.
Field Trip 1: Pre-Season Event Rocket Launch at NASA
WHO: Kids who have built rockets in Science Club during 2013/2014
WHAT: Rocket Launch
WHERE: NASA Ames Research Center https://maps.google.com/maps?hl=en&q=Moffett+Field,+Mountain+View,+CA
WHEN: September 20, 2014, 10 a.m. – 1 p.m.
WHAT TO BRING: Be prepared for hot weather; the event takes place on an asphalt airport runway. Please
bring lots of water and food (NO FOOD AVAILABLE to purchase on site); appropriate clothing (hats,
sunglasses); sunscreen; food; and a blanket to sit on. If you chose to bring your rocket home during the
summer, please bring your completed rocket with you. Don’t forget to bring both parts—the body and the
nose cone—in the box AND the cushioning material that you will wrap around your quail egg. Leslie will
provide engines for the rockets.
Parents: Be sure to bring your California driver’s license to get through the security gates.
This event is weather dependent. If it is excessively windy or drizzling, the launch will not take place.
Field Trip 2: NASA's Ames Research Center 75th Anniversary Open House
INFORMATION FROM NASA: “2014 will mark the 75th anniversary of Ames. On October 18, 2014, NASA is
inviting all of the Bay Area and Silicon Valley to come inside the gates and get to know NASA's center in
Silicon Valley. Take a two-mile walking tour through the center and visit with Ames engineers and scientists
in booths set up in front of their facilities. After the walking tour, join us on our plaza to learn about our
missions. Food, drinks and NASA gift shop merchandise will be on sale. This is a family-friendly event, and
children's educational activities will be offered.”
To reserve your free ticket, go to https://nasaamesopenhouse.eventbrite.com/. For more information about
the event: http://www.nasa.gov/ames/openhouse2014/#.VAdc-kt_1a8
Planned Field Trips (not yet confirmed)
Field Trip – With a medical doctor to discuss DNA
Field Trip – To UC Berkeley's Microbiology Department
6
Curriculum and Choices for 2014/2015
Each year, beginning members establish their physics and chemistry foundation while returning club
members build on the previous year's foundation to take their exploration to a new level. In Year 1 and Year
2, club members discover the incredible connections among atoms, molecules, organisms, and our universe
by studying chemistry (specifically atoms), physics (the force), biology (life study), and astronomy (the
universe). Year 1 introduces club members to physics and chemistry concepts. Year 2 revisits the concepts
from Year 1, thereby solidifying the knowledge that will serve as a solid foundation for their scientific futures.
Each club member needs two years of physics and chemistry to ensure that they grasp and then master these
concepts.
After completing two years of physics and chemistry, club members move to the Advanced Club Level. In
advanced clubs, we will cover the topics discussed above (neurology, geology/paleontology, rocketry and
robotics, and physics/chemistry review) on a rotating basis.
Club members can continue for as many years as they wish, building on their earlier foundation of chemistry
and physics to deepen their understanding of biology, physiology, neurology, geology/paleontology, and
robotics/rocketry.
Summary of Club Offerings
Year 1: Physics and Chemistry Foundation for new club members, beginning in kindergarten and up.
Year 2: Physics and Chemistry Foundation for returning club members who have completed Year 1.
Advanced Clubs are for members who have completed two years of Physics and Chemistry Foundation.
Maintaining Flexibility
To try to accommodate everyone's schedule, I am making time slots available on the weekend as well as
weekdays. Please see the schedule on page 9.
Regarding Soccer: If you are having a hard time finding a slot that works because your child is participating
in soccer during the fall, please let me know. In the past, it has worked to have a club member attend
whatever club meetings at their level are convenient during soccer season and then lock in a regular time
after the season ends.
Regarding Minimum School Days: I know that many schools have "minimum days" once a week. However, I
don't know all the schedules for every school. Therefore, I have left some 2:00 - 3:30 p.m. slots open on the
weekdays. If one of these slots would fit in with your school's minimum day schedule, please let me know. If
I have enough interest in a particular day I can create a club for that day and time.
Based on your feedback, my goal is to finalize the schedule by September 20. Please indicate on the club
day/time selection form (page 11) ALL the days that could possibly work for you, in addition to letting me
know your first, second, and third choices. This way I can make the best decisions taking into consideration
ages and prior science background. I would greatly appreciate your returning this initial signup form as
quickly as possible so that the dates you prefer can become part of my decision process. As always, please feel
free to call me with any questions you may have. I welcome your calls.
7
Tuition and Fees
Club tuition for the 2014/2015 year will be the same as it has been for the last six years: $985 if you pay in a
single installment (or $1,110 if you include the Field Trip Participation and Materials Fee).
A separate $125 Field Trip Participation/ Materials/ T-Shirt fee is due as a non-refundable deposit when you
sign up to cover materials and incidental costs associated with free field trips. While the trips are "free" in the
sense that there is no admission fee, ATOM Science Club often needs to create materials or provide lunches
for the people running the trips. The materials fee also serves as a deposit to reserve a spot for your club
member. This year, the fee also covers the cost of an ATOM Science Club Periodic Table T-shirt, which is a
wonderful teaching tool when kids wear them during meetings. Please note your T-shirt size on the form. If
you wish to order additional T-shirts, the cost is $25 each.
Your annual Field Trip Participation/Materials/T-Shirt fee of $125 will cover
 The cost of materials used during club meetings throughout the year.
 ATOM Science Club Periodic Table T-Shirt
 Free participation by club members and their families in all field trips that do not charge individual
admission per person. Included are field trips to locations such as Berkeley, Stanford, and NASA. I
will charge extra only for field trips to locations that charge additional per-person fees.
If you choose not to pay in full with your deposit, payment will be due according to the schedule below.
** Pay-in-full discount: If you pay both the materials fee/deposit and your tuition all at one time before
October 1, your total payment will be $1,110. I greatly appreciate your helping me keep the science club's
bookkeeping time and cost down so I can concentrate on adventure-filled club meetings and field trips.
PAYMENT
SCHEDULE
Pay in full on signup (before
Oct. 1, 2014)
Deposit plus One Payment
(before Oct. 1, 2014)
Two Payments
(before Jan. 15, 2015)
Three Payments
(before March 31, 2015)
DUE ON
SIGNUP
DUE
OCTOBER 1
DUE
JANUARY 15
DUE
MARCH 31
$1,110
TOTAL
DUE BY JAN.
15
$1,110
$125
$985
$1,110
$125
$500
$500
$125
$350
$350
$1,125
$350
$1,175
To guarantee your spot, please send in your deposit and signup materials (see signup process on page 10) as
soon as possible.
8
2014/2015 Schedule
As you review the proposed schedule, please note that the club meetings appearing in yellow shaded boxes
are the only ones that are definite. The others are all open/flexible to help accommodate your schedule. I
encourage you to provide me with input about what times work best for you. Providing several day/time
options that work for you, with choices ranked by numbers (#1 as your first choice), will make it much easier
for me to figure out a final schedule.
I hope to keep club members together so they can move ahead as a group. In order to make the club meetings
fun I need a minimum number of children in each group.
During the year, if club members miss their regular club meeting, they may do a make-up by attending a
different club at their level during that week.
Key to the Schedule
Yellow shaded boxes = Definitely scheduled levels and times of meetings (subject to minimum enrollment)
BLUE = Year 1 and Year 2: Physics and chemistry foundation.
GREEN = Advanced: More than 2 years with the club
MORNING
9:00
9:30
10:00
10:30
11:00
11:30
12:00
MON
9:00 – 10:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
TUES
9:00 – 10:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
WED
9:00 – 10:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
THUR
9:00 – 10:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
FRI
9:00 – 10:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
SAT
9:00 – 10:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
11 – 12:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
11 – 12:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
11 – 12:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
11 – 12:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
11 – 12:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
11 – 12:30
Home
Schoolers
Year 1
(Open if enough
enrollment)
2 – 3:30
(Open if enough
enrollment)
2 – 3:30
(Open if enough
enrollment)
2 – 3:30
(Open if enough
enrollment)
2 – 3:30
(Open if enough
enrollment)
2 – 3:30
(Open if enough
enrollment)
2 – 3:30
(Open if enough
enrollment)
3:30 – 5
(Open if enough
enrollment)
3:30 – 5
Continuing
from last year
3:30 – 5
(Open if enough
enrollment)
3:30 – 5
(Open if enough
enrollment)
3:30 – 5
(Open if enough
enrollment)
3:30 – 5
(Open if enough
enrollment)
5 – 6:30
(Open if enough
enrollment)
5 – 6:30
Year 3
(Continuing
from last year)
5 – 6:30
(Open if enough
enrollment)
5 – 6:30
Year 2
(Continuing
from last year)
5 – 6:30
(Open if enough
enrollment)
5 – 6:30
(Open if enough
enrollment)
AFTERNOON
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
7 – 8:30
Advanced
(Continuing
from last year)
8:00
Please contact Leslie at 650-271-2035 if you are unsure about which club is appropriate for your child.
9
Signup Process
To guarantee your spot for 2014/2015, I am requesting that you send in the following as soon as possible, but
no later than September 20:




your deposit of $125 (discussed on page 7); Please make check payable to ATOM Science Club for
Kids and write club member's name in memo field.
your club day/time selection form (page 11);
registration form* (page 12);
hold harmless agreement* (page 14).
All the pages with a BORDER at the end of this packet should be returned to me.
* I realize this is a lot of paperwork to fill out. However, it is very important for me to have registration
forms, which include up-to-date medical and contact information, before your child starts attending club
meetings. This is for the safety of your child.
Please indicate your preferred time or times and send your deposit check no later than September 15.
(Deposits are non-refundable, except in cases where I am unable to accommodate your requested time slot.)
You may then either pay the remaining balance in full, or in two or three payments when club meetings
resume in September.
Please fill out a separate set of forms for each club member.
Mail your completed forms to:
Madame ATOM
859 Overlook Court
San Mateo, CA 94403-3843
Refund Policy
While most club members look forward to club meetings and return year after year, I understand that the
program is not for everyone. My philosophy is that I don’t want any child to be participating in ATOM Science
Club who does not want to be here. I also understand that sometimes scheduling issues may arise midway
through the year.
To ensure that I fully understand the reasons behind any refund request, I now require requests to be made
during an in-person meeting at the ATOM Science Club House. This will help me improve the program by
understanding what issues may be going on with the child. You will need to speak with me on the phone to
set up an appointment. Once we have met I will be happy to issue a refund for the unused portion of your
payment.
THREE WAYS TO CONTACT MADAME ATOM
1) Send comments with the signup form
2) E-mail: [email protected]
3) Phone: 650-271-2035 (cell)
Thank you for your choice to participate in A.T.O.M. Science Club. I look forward to another wonderful year of
exploring, together, the wonders of the universe.
--Leslie (a.k.a. Madame Atom)
10
RETURN TO MADAME ATOM
Club Day/Time Selection Form
Please fill out a separate form for each club member.
Club Member Name ____________________________________________________Age: ________________________
REFER TO THE FULL SCHEDULE ON PAGE #8 FOR EXISTING CLUB DAYS/TIMES.
Please choose one of the following options and fill in the requested information as necessary:
____ I want to continue in last year's time slot, which was: _______________________________________
____ I want to continue but I'm not sure yet what time slot will work
__ I want to continue and have indicated my choices for days/times in the table below (please rank your choices by
placing a number in the appropriate box, with #1 indicating your first choice, #2 your second choice, etc.)
9:00
9:30
10:00
11:00
11:30
12:00
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
MON
9 – 10:30
TUES
9 – 10:30
THU
9 – 10:30
THU
9 – 10:30
FRI
9 – 10:30
SAT
9 – 10:30
_____________
11 – 12:30
_____________
11 – 12:30
_____________
11 – 12:30
_____________
11 – 12:30
_____________
11 – 12:30
_____________
11 – 12:30
_____________
2 – 3:30
_____________
2 – 3:30
_____________
2 – 3:30
_____________
2 – 3:30
_____________
2 – 3:30
_____________
2 – 3:30
_____________
3:30 – 5
_____________
3:30 – 5
_____________
3:30 – 5
_____________
3:30 – 5
_____________
3:30 – 5
_____________
3:30 – 5
_____________
5 – 6:30
_____________
5 – 6:30
_____________
5 – 6:30
_____________
5 – 6:30
_____________
5 – 6:30
_____________
5 – 6:30
_____________
_____________
_____________
_____________
_____________
_____________
7 – 8:30
_____________
Please contact Leslie at 650- 271-2035 if you are unsure about which club is appropriate for your child.
Contact Parent's Name _________________________________ Contact Parents' Phone: Land # (_______)____________________
Contact Parent's E-mail _________________________________ Cell # (_______)____________ Work # (_______)______________
PAYMENT DUE WITH THIS FORM
Please make check payable to ATOM Science Club for Kids and write club member's name in memo field.
______ $125
OR
______ $1,110 pay-in-full ______ $25 Additional optional T-shirt
T-shirt size for included T-Shirt:
Child M ____ L ____
Adult S ____ M ____ L ____
T-shirt size for additional T-Shirt: Child M ____ L ____
Adult S ____ M ____ L ____
Tuition payment due in full or in installments beginning no later than the end of the first week of club meetings
(October 1). See tuition information page for amounts and options. *REMINDER: If you pay in full now, you will
receive the maximum reduced rate.
11
A.T.O.M. Science Club for Kids
RETURN TO MADAME ATOM
2014-2015 REGISTRATION FORM
Thank you for joining Adventures Through Open Minds Science Club for Kids
A.T.O.M. Science Club for Kids will hold meetings from the end of September 2014 through the end of May 2015.
Please fill out a separate form for each club member and mail it with your non-refundable deposit/materials check or payment
in full (make check payable to ATOM Science Club for Kids) to:
Madame ATOM
859 Overlook Court
San Mateo, CA 94403-3843
I greatly appreciate you taking the time to print clearly so my office staff and I can read your information. Thank you!
Club Member’s Name _________________________________________________________________________________________________________________
Address _________________________________________________________
City ______________________________________________________________ State________ Zip ________
Home Phone __________________________________ Age ________
Birth Date_______________________________________________________
Mother’s Name_________________________________________________ Father’s Name __________________________________________________
Work Phone ____________________________________________________ Work Phone ____________________________________________________
Cell Phone ______________________________________________________ Cell Phone _______________________________________________________
E-Mail __________________________________________________________ E-Mail __________________________________________________________
Please print carefully so I can be sure to be able to e-mail you. Thank you very much!
Please provide two emergency contact names:
1) Name ___________________________________________
Phone __________________________________________________________
Relationship _______________________________________
Cell _____________________________________________________________
2) Name ___________________________________________
Phone __________________________________________________________
Relationship _______________________________________
Cell ______________________________________________________________
Doctor/Pediatrician _________________________________
Phone __________________________________________________________
Dentist ________________________________________________
Phone __________________________________________________________
Insurance Company _________________________________
Please list any medical conditions or allergies (we have snack during club time)
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
12
RETURN TO MADAME ATOM
REGISTRATION FORM PAGE 2 Club Member’s Name ___________________________________________
POLICIES
 All members are encouraged to attend weekly meetings because each meeting builds on previous meetings.
 If your child is ill, please do not send them to science club. Your child may make up a club at another time.
 If the club member misses their regular meeting, they may attend another club session at their level during the same
week. Please let Madame ATOM know beforehand to ensure there is space available in the other meeting.
 Club members must wait inside until a parent or guardian picks them up.
 Parent/Guardian is required to come inside to pick up a child.
Please send a note if someone else besides the parent is picking up your child. If this person(s) will be consistently picking up
your child, please fill in the following:
Name _____________________________________________ Phone _______________________________________
Name _____________________________________________ Phone _______________________________________
Name _____________________________________________ Phone _______________________________________
Upon rare occasions, I may need to reschedule a club session. In that event, I will work with that club to either reschedule club
or have the children attend another club at their level.
Potential club members may attend one club meeting with a parent free of charge. The parent/guardian must stay with the
child during the entire club meeting.
If you know of a potential club member, please let them know that they may attend one club with a parent free of charge.
THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS A.T.O.M. Science Club for Kids, its owner or if
applicable its directors, officers, employees or agents and each of them from any loss, liability damage, expense (including
reasonable attorney’s fees) that A.T.O.M. Science Club for Kids, its owner or if applicable its directors, officers, employees or
agents may incur due to the presence of the undersigned or Participant in or about the A.T.O.M. Science Club for Kids premises
or by any participation in any program or activity offered by or affiliated with A.T.O.M. Science Club for Kids, whether or not
caused by the negligence of A.T.O.M. Science Club for Kids, its owner or if applicable its directors, officers, employees or agents.
I have read and agree to abide by the policies for A.T.O.M. Science Club for Kids.
Parent / Guardian Signature ______________________________________________________ Date ___________________________
Siblings not attending A.T.O.M. Science Club (optional):
Name_________________________________________
Birth Date ______________________________________
Name _________________________________________
Birth Date ______________________________________
Thank you for your choice to participate in A.T.O.M. Science club. I look forward to wonderful year of exploring, together, the
wonders of the universe. – Leslie (a.k.a. Madame Atom)
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RETURN TO MADAME ATOM
RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
TERMS OF USE for 2014-2015
The undersigned, the parent or legal guardian of _______________________________________, a minor (hereinafter
referred to as “Participant”), in consideration of enrollment of Participant in the programs offered by ADVENTURE
THROUGH OPEN MINDS (hereinafter referred to as “A.T.O.M.”) Science Club for Kids (either a sole proprietorship or as
a California Corporation), himself or herself and on behalf of Participant and any personal representative or heirs, hereby
acknowledges, agrees and represents that he or she has carefully considered enrollment of Participant in the programs
presented by A.T.O.M. Science Club for Kids and after careful consideration and inquiry regarding said program has decided
to enroll Participant in said programs. The undersigned further acknowledges and represents that he or she shall have
reasonable and full opportunity to inspect the premises operated by A.T.O.M. Science Club for Kids and to complete inquiry
regarding the nature and extent of said programs at any time so desired. It is understood that club activities may include the
following:
1. The programs presented by A.T.O.M. Science Club for Kids are intended for participation by children only. A.T.O.M.
Science Club has the sole right to limit registration for any reason.
2. From time to time Participants will participate in field trips and excursions away from the primary club premises.
Transportation to or from field trips or to and from any club activity is not provided. On such occasions,
parents/guardians shall have the full and sole responsibility for transportation of their Participant(s) to the location of
the field trip, supervision of all participant(s) under the care of participating parent/guardian at all times during any
field trips and for return of the Participant(s) from the field trip.
A.T.O.M. Science Club for Kids, its owner or its officers, directors, shareholders or agents as applicable, shall not be
responsible in any way for the transportation of Participants and shall not be responsible for the supervision, care, safety or well
being of any Participant(s) or their participating parents/guardian.
1. A.T.O.M. Science Club for Kids, its owner or its officers, directors, shareholders or agents as applicable are not
responsible for insuring arrival or participation of participants and do not take or keep attendance records, nor do they
take roll at any particular session. The club is not responsible for the care or custody of participants outside of
scheduled club meetings. Parents must arrange for the safe pick-up of Participants at the designated times. In the event
that there are any late pick-ups fees will be charged at the discretion of A.T.O.M. Science Club for Kids.
2. A.T.O.M. Science Club for Kids, its owner or its officers, directors, shareholders or agents as applicable, are not
responsible for damage to or loss of property of Participant before, during or after club activities. The club is not
responsible for damage that a participant may do to the club premises and, in appropriate instances, Participants and
their parents/guardians may be held liable for their negligence or willful misconduct.
3. From time to time, A.T.O.M. Science Club for Kids may sponsor Outward Bound or overnight camping trips or
adventures. Participation in these trips is subject to the release and indemnification provisions of this agreement set
forth below.
IN FURTHER CONSIDERATION OF PARTICIPATION IN A.T.O.M. SCIENCE CLUB FOR KIDS, THE
UNDERSIGNED, ON BEHALF OF PARTICIPANT, HEREBY AGREES TO THE FOLLOWING:
I recognize that there are risks to my child's person and property in participating in any activity, including A.T.O.M.
Science Club for Kids. I also understand that A.T.O.M. Science Club for Kids could not afford to offer the courses and
activities it does if it were required to bear the sole financial responsibility for those risks. Therefore, in order to induce
A.T.O.M. Science Club for Kids to make its programs available to my child/ward, I agree to share the risk of loss arising from
injury to my child/ward and/or her/his property with A.T.O.M. Science Club for Kids by entering into this indemnification
agreement in which I accept responsibility for all losses. I am aware that my child/ward will also be exposed to the risks of
surface travel in cars or other forms of transportation and while participating in A.T.O.M. Science Club for Kids activities, I
accept the full responsibility for those risks.
A.T.O.M. Science Club for Kids Hold Harmless Agreement Page 1 of 2 Last revised 9/20/2010
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RETURN TO MADAME ATOM
A.T.O.M. Science Club for Kids Hold Harmless Agreement Page 2 of 2
Club Member's Name: ___________________________________
1. THE UNDERSIGNED, FOR MYSELF AND FOR MY CHILD/WARD hereby release, waive, discharge and
covenants not to bring any action, legal or otherwise, against A.T.O.M Science Club for Kids, its owner or directors, officers,
employees or agents as applicable. In addition I release from liability A.T.O.M. Science Club for Kids and its directors,
officers, employees and agents from any loss, damage, claims or demands related to injury or property loss.
2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS
A.T.O.M. Science Club for Kids its owner or directors, officers, employees or agents as applicable and each of them from any
loss, liability damage, expense (including reasonable attorney’s fees) that A.T.O.M. Science Club for Kids, its owner or
directors, officers, employees or agents as applicable may incur due to the presence of the undersigned or Participant in or about
the A.T.O.M. Science Club for Kids premises or while participating in any program or activity offered by or affiliated with
A.T.O.M. Science Club for Kids, whether or not caused by the negligence of the A.T.O.M. Science Club for Kids, its owner or
directors, officers, employees or agents as applicable.
3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND OF ANY RISK OF BODILY
INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or Participant due to the negligence of A.T.O.M. Science
Club for Kids, its owner or directors, officers, employees or agents as applicable or any other reason while the undersigned or
Participant is in or about the premises of A.T.O.M. Science Club for Kids or while participating in any program or activity
offered by or affiliated with A.T.O.M. Science Club for Kids.
THE UNDERSIGNED FURTHER EXPRESSLY AGREES that the foregoing RELEASE, WAIVER AND
INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the laws of the State of California
and that if any portion thereof is held invalid, it is agreed that the remaining portions of this agreement shall continue in full
force and effect. It is the intention of the parties that this RELEASE, WAIVER AND INDEMNITY AGREEMENT shall
operate as a full and complete bar to any claims that may be presented by the undersigned or Participant or their personal
representatives, heirs or assigns with respect to any claim, proceeding or litigation brought by or on behalf of the undersigned or
Participant. No oral representations, statements or inducements apart from what is set forth in this written agreement have been
made.
THE UNDERSIGNED HAS READ, UNDERSTANDS AND VOLUNTARILY SIGNED THIS RELEASE,
WAIVER AND INDEMNITY AGREEMENT.
Dated: __________________
Printed Name of Participant: _______________________________________________________
Printed Name of Parent or Guardian: ________________________________________________
Signature of Parent or Guardian: _____________________________________________
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