Fill out the form below. If you have any questions, please contact The MiX. Contact Information Student Name * School Name * Phone * Current Grade Level * - Select -9101112 Home Address * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip / Postal Code * Email Address * Parent Contact Information Parent / Guardian Name * Daytime Phone * Evening Phone Emergency Contact Information Emergency Contact Name * Relationship * Emergency Contact Phone * Physician's Phone * Student's Primary Physician * Existing Medical Conditions The MiX Media ReleaseThe MiX may use photographs, digital images, video or audio tapes of my child for the purpose of illustration, advertising, trade or publication in any manner on behalf of the Science Museum of Virginia. Media Release Options * I give my consent. I do not give my consent. Parental ConsentI give permission for my child to become a member of The MiX and to participate in activities associated with The MiX. Electronic Signature * Yes, I give my child consent to become a member of The MiX. Math question * 8 + 0 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.