Girl Genius Club Registration Form

Please List Your School/Location *

Please click the session(s) you would like to register

Fall 2017 Spring 2018

Day of the Week

(1) Participant *

First Name Last Name

(1) Participant's Grade Level *

(2) Participant

First Name Last Name

(2) Participant's Grade Level

Parent/Guardian

First Name Last Name

Email *

Phone Number *

Area Code Phone Number

Authorized for pick up.

First Name Last Name

Authorized for pick up.

First Name Last Name

Additional Emergency Contact

First Name Last Name

Phone Number

Area Code Phone Number

Additional Emergency Contact

First Name Last Name

Phone Number

Area Code Phone Number

Chronic or reoccurring allergies, illnesses or medical conditions:

Activities discouraged or limited by physician:

Dietary Restrictions:

Waiver
1) My child has permission to participate in all activities unless otherwise specified in writing. I understand that the Beauty & Brains Girls STEM Club, LLC assumes no responsibility for injuries or illness my child may receive as a result of his/her participation in After-School programs, athletic activities, the use of any equipment, exercise or other activities. I expressly acknowledge that I assume the risk for any and all injuries and all illnesses which may result from his/her participation in these activities. In consideration of the privilege of participating at the Beauty & Brains Girls STEM Club, LLC, I hereby voluntarily release and discharge Beauty & Brains Girls STEM Club, LLC its agents, servants, and employees from any claims for injury, illness, death, and / or loss of damage which my child may suffer as a result of his/her participation in these activities. 2) I hereby give my permission to the medical personnel selected by the Beauty & Brains Girls STEM Club, LLC to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in emergency, I hereby give permission to the physician selected by Beauty & Brains Girls STEM Club, LLC to secure and administer treatment, including hospitalization for my child. I understand and acknowledge that: (i) it is the responsibility of the parent(s)/guardian to make full disclosure to the Beauty & Brains Girls STEM Club, LLC any special circumstances which may affect the ability of my child/ward to participate, as described above; (ii) it is the responsibility of the parent(s)/guardian to inform the Beauty & Brains Girls STEM Club, LLC of any requested accommodation believed by the parent(s)/guardian to be necessary and readily achievable for such participation; and (iii) full disclosure of any special circumstances is material to the Beauty & Brains Girls STEM Club, LLC of the child’s/ward’s ability to participate and the Beauty & Brains Girls STEM Club, LLC of any requested accommodation. 3) I understand that no accident or medical insurance is provided with any activity while my child is at camp. 4) I give permission to the Beauty & Brains Girls STEM Club, LLC without limitation or obligation for photographs, film footage, or tape recordings which may include my child’s image or voice for purposes of promoting or interpreting Beauty & Brains Girls STEM Club, LLC and release the Beauty & Brains Girls STEM Club, LLC any claim of liability to that use. 5) I understand the payment for the program is my responsibility and failure to comply will result in removal from the program. . 8) I understand that all payments will be made by automatic draft, either bank account or credit card payment, in advance. 9) While in the Beauty & Brains Girls STEM Club, LLC, every effort will be made to provide reasonable accommodations for mentally and physically challenged children. Beauty & Brains Girls STEM Club, LLC will not accept children who are (A) of danger to themselves (B) of danger to others, or (C) a disruption to normal activities making it unreasonably difficult for other children to enjoy the programs. Any of the above reasons will be grounds for dismissal. A parent/guardian must discuss specific special conditions involving their child with the director. This must be completed prior to registration so that the administration may make a determination if reasonable accommodations can be made for your child. 10) I have read and agreed to all of the policies set forth by Beauty & Brains Girls STEM Club, LLC.

Please check your preferred payment option. *

I would like to pay the tuition in full and receive a FREE Girl Genius Club t-shirt. Please pay your full tuition in the payment section below. I would like to pay the tuition in two separate payments. Please pay 1/2 of the tuition in the payment section below. A digital invoice and payment schedule will be sent to your email address for the remaining balance. I would like to pay the tuition in three separate payments. Please pay 1/3 of the tuition in the payment section below. A digital invoice and payment schedule will be sent to your email address for the remaining balance.

Participant (1) Club T-Shirts $13.00 each FREE with full tuition payment.

Youth Small (4-6) Youth Medium (8-10) Youth Large (12-14) Adult Small Adult Medium Adult Large Adult X- Large

Participant (2) Club T-Shirts $13.00 each FREE with full tuition payment.

Youth Small (4-6) Youth Medium (8-10) Youth Large (12-14) Adult Small Adult Medium Adult Large Adult X- Large

Total Payment

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Credit Card Details
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Credit Card Details
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I have read and agree to the above terms and requirements. *

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