Registration - Brainy Learning Club

Name*
First Last
Date of Birth
MM
DD
YYYY
Gender
- M
- F
Tutoring for OR Desired Camp Dates
Contact Parents/Guardians
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State ZIP Code
As a parent or guardian of this student, I hereby consent to the use of photographs taken by Brainy Learning Club for publicity and promotional advertisements including publications, presentation or broadcast via newspaper, internet or other media sources. I do this with full knowledge and consent and waive all claims for compensation for use, or for damages.*
- YES I consent
- NO I do not consent
Additional Emergency Contacts
Name
First Last
Phone
Name
First Last
Phone
If registering for camp
Medical Information: Participant must be covered by family medical/hospital insurance, and be up to date on all immunizations.
Name of primary doctor(s) & Phone number(s)
Health Insurance Information
Subscriber’s Name
Insurance Company Name
Insurance Company Phone
Subscriber Number
Policy Number
Allergies and Diet
Does the participant have any known allergies?
- Yes
- No
If YES, please select all that you are allergic to
If you selected other, please describe what the participant is allergic to and reaction seen
Please indicate action to be taken and any medication to be administered in case of an allergic reaction (mild or severe)
Restrictions
I have reviewed the program of the class and feel my son/daughter can participate
- Without restrictions
- With restrictions or adaptations
Please specify the restrictions or adaptations
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
Parent/Guardian Name
Relationship to Child
Date
Amount to Pay
Processing Fee (3%)
Price: $0.00
Total Payment
$0.00

Contact Parents/Guardians

Additional Emergency Contacts

If registering for camp

Health Insurance Information

Allergies and Diet

Restrictions

Parent/Guardian Authorization