Child Information
Child's Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Age
*
Grade Entering in Fall 2025
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Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Please list any known allergies
*
Medical conditions or special needs staff should know about
*
Physician Name and Phone Number
*
Insurance Carrier and Policy Number
*
How did you hear about Brainzium?
*
Please Select
Returning Family
Friend or Referral
Social Media
Flyer or Poster
School
Other
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Parent & Guardian Information
Parent/Guardian 1 Full Name
*
First Name
Last Name
Relationship to Child
*
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Employer Name
*
Work Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Full Name
*
Parent 2 Relationship to Child
*
Parent 2 Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent 2 Email Address
*
example@example.com
Preferred Contact Method
*
Please Select
Text
Call
Email
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Emergency Contacts
Emergency Contact 1 Full Name
*
First Name
Last Name
EC1 Relationship to Child
*
EC1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 Full Name
*
EC2 Relationship to Child
*
EC2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Authorized Pickup
Authorized Pickup Person 1 - Name and Relationship
*
Authorized Pickup Person 1 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup Person 2 - Name and Relationship
*
Authorized Pickup Person 2 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup Person 3 - Name and Relationship
Optional — Type N/A if you do not have a 3rd authorized pickup person
Authorized Pickup Person 3 - Phone Number
Optional — Type N/A if no 3rd pickup person
Format: (000) 000-0000.
Authorized Pickup Person 4 - Name and Relationship
Optional — Type N/A if you do not have a 4th authorized pickup person
Authorized Pickup Person 4 - Phone Number
Optional — Type N/A if no 4th pickup person
Format: (000) 000-0000.
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PARENT HANDBOOK — I have read the Brainzium Parent Handbook. I agree to abide by all policies. I understand policies may change and I will be notified of significant updates. Repeated non-compliance may result in removal from the program.
Initials — Parent Handbook
*
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EMERGENCY PROCEDURE — In an emergency I authorize Brainzium staff to contact my emergency contacts and authorize the listed physician to provide medical treatment. If contacts cannot be reached, Brainzium staff may take necessary action for my child's health and welfare.
Initials — Emergency Procedure
*
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STUDENT RECORDS — I agree to keep my child's enrollment, emergency forms, and health records current in the Brainzium system. I will promptly notify staff of any changes to medical info, emergency contacts, or authorized pickup persons.
Initials — Student Records
*
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SIGN IN/OUT POLICY — I agree to Brainzium sign in/out procedures. Brainzium is not responsible for my child before sign-in or after sign-out.
Initials — Sign In/Out Policy
*
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PARENT COMMUNICATIONS POLICY — Brainzium uses email, text messages, and phone calls to reach parents for urgent updates, emergencies, and general communication. I agree to keep all contact information and emergency contacts current, check messages regularly while my child is in care, and respond promptly to all Brainzium communications.
Initials — Parent Communications Policy
*
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PAYMENT POLICY — Tuition is due each Friday by 5:00 PM for the following week of care. I agree to abide by all payment policies in the Brainzium Parent Handbook. I understand that if I do not follow the payment policy, my child will not be allowed to attend Brainzium until the balance is paid in full. Any additional fees must be paid within 72 hours of receipt.
Initials — Payment Policy
*
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ACTIVITY RELEASE — I authorize my child to participate in all arts and crafts, science, cooking, gym games, outdoor games, homework time, planned field trips, and other activities organized by Brainzium staff.
Initials — Activity Release
*
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PHOTO AND SOCIAL MEDIA CONSENT — I give permission for my child to be photographed during Brainzium program activities. These photos may be used in Brainzium social media posts and newsletters. My child's name will not be included in any published photo without additional written consent.
Initials — Photo and Social Media Policy
*
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SUNSCREEN POLICY — Brainzium staff may assist or apply sunscreen to my child when needed. My child must bring their own sunscreen with SPF 30 or higher in its original labeled container. If my child does not have sunscreen, sun exposure will be limited or denied.
Initials — Sunscreen Policy
*
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TV AND TRANSPORTATION — Television and movies at Brainzium will be age-appropriate and shown minimally with parental consent. I give permission for my child to be transported in approved vehicles for field trips. I will be notified in advance of all field trips.
Initials — TV and Transportation
*
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CELL PHONE POLICY — Students may NOT carry cell phones on their person during the program day. Phone use is only allowed during designated times set by staff. To reach your child during program hours, call Brainzium directly at (720) 694-4542. Any confiscated phone will be returned ONLY under direct parent or guardian supervision at pickup.
Initials — Cell Phone Policy
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Final Signature & Submission
By signing below, you confirm you have read and initialed all Brainzium policies and that all information in this registration is accurate and complete.
Parent/Guardian Printed Name
*
Today's Date
*
-
Month
-
Day
Year
Date
Parent/Guardian Signature
*
I certify all information is accurate and I agree to all Brainzium Summer Care Program policies and procedures.
*
Submit Registration
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