Brainiacs Science Discovery Center

Please bring this form to your first class or camp. (Please include your email so we can send you a confirmation of registration)

CHILD’S NAME
PARENT’S NAME
STREET ADDRESS
CITY AND ZIP CODE
HOME PHONE
CELL PHONE
EMERGENCY CONTACT AND PHONE:

EMAIL ADDRESS

ALLERGIES OR MEDICAL PROBLEMS


How did you hear of Brainiacs?


PLEASE READ AND SIGN BELOW: I have read the make-up and refund policy. I understand that to receive any credits for make-up classes or camps, I must notify Brainiacs by phone prior to the start of the class and by 8:30 am on the day of the camp. (The make-up and refund policy can be found on our web site at www.BrainiacsScience.com.)

Parent name
Parent signature
Please bring this form to your first class or camp. (Please include your email so we can send you a confirmation of registration)