Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Gender *

Male

Female

Home Phone *

(###)

###

####

Child's Permanent Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child's legal status allow them to reside in the US? *

Proof of immigration status or U.S. Citizenship will be required upon enrollment.

YES

NO

Grade Level *

Day Care

Pre - K

Kindergarten

1st Grade

2nd Grade

3rd Grade

Primary Parent/Guardian Name *

First Name

Last Name

Primary Parent/Guardian Gender *

Male

Female

Primary Parent/Guardian Phone Number *

(###)

###

####

Primary Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Parent/Guardian Name

First Name

Last Name

Secondary Parent/Guardian Gender

Male

Female

Secondary Parent/Guardian Phone Number

(###)

###

####

Primary EMERGENCY Contact Name *

First Name

Last Name

Primary EMERGENCY Contact Phone *

(###)

###

####

Secondary EMERGENCY Contact Name

First Name

Last Name

Secondary EMERGENCY Contact Phone

(###)

###

####

MEDICAL: Does your child have any allergies? *

If YES, please list below.

YES

NO

Any Medical Conditions (e.g., Asthma, Diabetes, Epilepsy): *

If YES, please list below.

YES

NO

Doctor's Name:

First Name

Last Name

Doctor's Phone Number:

(###)

###

####

Statement of Understanding *

I have read and understand the information contained in this registration form and agree to abide by the rules and regulations of Brighter Minds Learning Center's program/activity. I understand that the information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts may be cause for rejection of this application or termination of registration. I authorize Brighter Minds Learning Center to verify the information provided in this application, including contacting my emergency references. I understand that this application is NOT a completion of enrollment. Release and Consent Medical Treatment Consent: In the event of an emergency where I cannot be reached, I hereby give permission for the program staff to seek appropriate medical attention for my child. I understand that every effort will be made to contact me immediately. Photo/Video Release: I grant Brighter Minds Learning Center permission to use photographs and/or video recordings of my child taken during program activities for promotional purposes (e.g., website, social media, newsletters). I understand that my child's name will not be used without further consent. Liability Waiver: Upon enrollment, I understand and agree that Brighter Minds Learning Center, its employees, contractors and volunteers are not liable for any injury or illness that may occur during the program activities. I am registering my child with the understanding of potential risks involved.

I AGREE