• Contact Parents/Guardians

  • Additional Emergency Contacts

  • If registering for camp

    Medical Information: Participant must be covered by family medical/hospital insurance, and be up to date on all immunizations.
  • Health Insurance Information

  • Allergies and Diet

  • Restrictions

  • Parent/Guardian Authorization

    This health history is correct and accurately reflects the health status of the participant to whom it pertains. My son/daughter has permission to participate in all class activities except as noted by me/or an examining physician. If I cannot be reached in an emergency, I give permission to Brainy Learning Club to get my son/daughter to an emergency room in the most expedient manner possible. Additionally, I give permission for a physician selected by Brainy Learning Club to hospitalize and secure proper treatment, including but not limited to ordering injections, anesthesia, surgery, x-rays and other tests related to the health of my son/daughter. I understand this information on this form will be shared only on a “need to know” basis with Brainy Learning Club. I give permission to photocopy this form. In addition, Brainy Learning Club has permission to obtain a copy of participant’s health record from treating providers and these providers may talk with the program’s staff and/or emergency personnel about related health status in the event of an emergency

  • Price: $0.00
  • $0.00