Course Registration Form

Parent/Guardian Details

First Name

Last Name

Parent/Guardian Email

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Additional Parent/Guardian Details

First Name

Last Name

Parent/Guardian Email

Phone/Mobile

Student Details

First Name

Last Name

Student Email

Grade Level

Date of Birth

Gender

Male

Female

Current School

Course Selection

Course

Health Information

Allergies

Medical Conditions

Special Medication or Care Required

Primary Care Physician Name

Primary Care Physician Phone

Emergency Contact

Please list emergency contact information for any individual other than the parent/guardian.

First Name

Last Name

Phone/Mobile

Relationship to Student

Parental/Guardian Supervision Requirement

Students under the age of 13 must be accompanied by a parent, guardian, or another adult over the age of 18. The accompanying individual must remain on the premises for the entire duration of the student’s class.

I have read and agree to abide by the supervision requirement for students under the age of 13.

Release of Liability

Parent/Guardian indemnifies, holds harmless, and forever discharges Bright Minds Learning Labs (BMLL), its agents and employees from all claims and liabilities, whether known or unknown, arising from in any way related to Student or Parent's BMLL services. This specifically includes a release for any laboratory activities or scientific experiments done on premises. It also includes any general damages or liability related to the premises and services offered. This does not apply to acts of gross negligence, or intentional, willful, or wanton misconduct.

I have read and agree to the Release of Liability.

Consent for Medical Treatment

In the case of medical emergency, BMLL may need to provide medical treatment or contact medical personnel. Parent/Guardian provides authorization for this treatment. BMLL will contact Parent/Guardian or other emergency contact as soon as reasonably possible with respect to any emergency or other medical treatment needed.

I have read the Consent for Medical Treatment and provide authorization for medical treatment.