Brain Builders Learning Academy, Inc. (School Application Form)

Enrollment Form
Student Information
Student's Picture*
Student's Name *

First NameMiddle NameLast Name
Age *
FemaleMale
Birth Date*

MonthDayYear
Birthplace*
Religion*
Student Email*
Address*

Street Address

Street Address Line 2

CityProvince

Zip Code
Level/Grade*
Parent/Guardian Information
Parent/Guardians Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Zip Code
Home

Area CodeNumber
Cell*

Area CodeNumber
Email*
Numbers to Ring In case of Emergency & Relationship to the Child.
Contact Name*

First NameMiddle NameLast Name
Relationship To Child*
Home

Area CodeNumber
Cell *

Area CodeNumber
Other Information
Password if someone else is picking up the child.*
Does your child have any known emotional or behavioral problems? If Yes, Please state in brief what and discuss this with Brain Builders*
Please give brief detail
Does your child have Epilepsy ? If Yes, please advise Brain Builders as breathing exercises may trigger a seizure*
Does your child have severe allergies/anaphylaxis?*
Does your child have Asthma ? If Yes, please advise Brain Builders & ensure they bring their inhaler*
Is your child taking any medication, if Yes please give details*
Please give detail
Please complete the following to the best of your knowledge and discuss any specific concerns you have with me and together we can support your child.

Rows	Excellent	Good	Ok	Needs some extra support	Needs lots of extra support
Ability to be calm and peaceful at times.
Ability to deal with anxiety and stress.
Ability to express their feelings.
Self-esteem and self-confidence.
Ability to cope with feelings of Anger
Ability to openly show care and concern for themselves and others
Attention span.
Ability to listen
Sleep pattern.

Enrollment Form