Kinder Prep Registration

Registration Form

Student Name*
First Last
Nick Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Name*
First Last
Emergency Contact Phone*
Emergency Contact Email*
Newsletter Opt-In*
- Yes
- No
Parent/Guardian Information
Full Name*
First Last
Relationship*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Email*
Full Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Email
This student may be released to the person signing this agreement or to the following individuals:
Name
First Last
Relationship
Cell Phone
Name
First Last
Relationship
Cell Phone
Name
First Last
Relationship
Cell Phone
Medical Information
Student's Physician or Clinic's Name (Primary Health Provider/Source):*
Doctor/Clinic Name:*
Phone*
Is your student on any medication?*
- Yes
- No
(If YES, please list below all medications and their purpose.)
Please list all of your student's medications and reasons:
Does your student have any health issues we need to be aware of?*
- Yes
- No
(If YES, please describe below in detail)
Please explain your student's health issues we need to be aware of:
Does your student have any food, medication, or environmental allergies?*
- Yes
- No
(If YES, please describe below in detail)
Food Allergies:
Medication Allergies:
Environmental Allergies:
Please list any dietary restrictions:
Please list any exercise restrictions:
I hereby give permission for images of my child, captured during his or her time at the Brain Zone Reading & Learning Center, Inc. through video, photo and digital camera, to be used solely for the purposes of promotional material and publications, and waive any rights of compensation or ownership thereto.*
- Yes
- No
I verify the above information to be true and correct. As the parent or guardian of this child, I hereby give my permission for this child to attend educational classes and participate in age appropriate games, exercises, activities, and snack at the Brain Zone.*
Signature your name above
Comments
This field is for validation purposes and should be left unchanged.

Name
First Last
Email
Email
This field is for validation purposes and should be left unchanged.

Changing Lives in Chino Hills Since 2002

Kinder Prep Registration

Registration Form

Parent/Guardian Information

This student may be released to the person signing this agreement or to the following individuals:

Medical Information

Newsletter Signup

Providing Educational Services to ALL Types of Learners

Programs

Process

Resources

Contact Us