Brainiacs Science Discovery Center

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Please check appropriate box
4 WEEK SESSION
8 WEEK SESSION
12 WEEK SESSION
CHILD’S NAME
STREET ADDRESS
CITY AND ZIP

CHILD’S BIRTHDATE
HOME PHONE
CELL PHONE
WORK PHONE
EMAIL ADDRESS

EMERGENCY CONTACT AND PHONE:


DAY AND TIME OF CLASS:
1ST CHOICE
2ND CHOICE (OPTIONAL)

DOES YOUR CHILD HAVE ANY ALLERGIES? PLEASE LIST OR WRITE NONE.


DOES YOUR CHILD HAVE ANY MEDICAL PROBLEMS OR LEARNING DISABILITIES? PLEASE LIST OR WRITE NONE.


PLEASE READ AND SIGN BELOW: I confirm that my child is able to follow directions and participate in a 45 minute science lesson without being disruptive to the class or interfering with the other students’ experiments. I understand that enrollment may be refused to my child if he/she has disruptive behavior or cannot observe the Science Lab Safety rules.

Parent name
Parent signature
(PLEASE PRINT THIS FORM AND MAIL OR BRING TO THE CENTER) We accept Visa and Mastercard payment