Club Registration
Host School *
Parent Name *
Your answer
Phone Number *
Your answer
Address *
Your answer
Email Address *
Your answer
Student Name *
Your answer
Student Birth Date *
MM
/
DD
/
YYYY
Student Gender
Student Grade *
Teacher's Last Name *
Your answer
Please list anyone, including yourself, authorized to sign your child out of our care. If you would like your student to sign themselves out, please email us separately with that authorization at office@brainstemaz.com. *
Your answer
Please list any allergies or health concerns, or mark N/A if none. *
Your answer
Are there any custody issues that we should be aware of?
Your answer
Will your child attend aftercare after our class ends? *
Emergency Contact Name (parent will be called first) *
Your answer
Emergency Contact Number *
Your answer
Additional Notes:
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Would you like to receive e-newsletters from Brain STEM?
Would you like to receive a coupon for $50 off of a Brain STEM birthday party? (Included with paid club registration.)
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