Clone of STEM Enrichment Registration Form

BrainyBuilders Registration Form

This form is for first time registering only. Returning users, will complete Returning Registration Form. Please complete one form per child. Those registering multiple children will need to fill out multiple forms.
Parent First Name*
Parent Last Name*
Parent Address*
City*
State*
Zip *
Parent (Guardian) Phone Number*
Please enter a valid phone number.
Parent (Guardian) Name Email*
example@example.com
Student Name*

First NameLast Name
Student Age*
Student's Gender*

MaleFemale
Student's Race*

Black/African-AmericanHispanicWhite/CaucasianNative AmericanMultiracial/Two or More RacesOther
Student's Grade (as of 2025-2026 School Year)*
What school will your child attend this year?*
Does your child receive free or reduced lunch? (We use this information for data during grant submissions)
Emergency Contact *
Emergency Contact Phone Number*
Please enter a valid phone number.
In case of an emergency for which we have to contact EMS, which hospital would you like for us to transport your child? (Please see Medical Care Waiver below)*
Is there anything we should know about your child? (allergies, medications, asthma, physical limitations or accommodations etc. if not please type N/A) *Please note that we do not administer medications to youth**
Does your child have special learning needs that we need to be aware of? (If not, please type N/A)*
How will your child arrive at our center?
List any family members or adults 18 years or older authorized to pick up your child. *We will NOT release your child to any adult who is not listed here*
Waivers and Releases

Please read the following documents and acknowledge by signing below
Parent Agreement & Program Policies

Liability Waiver

Medical Authorization

Behavior Expectations

Photo and Social Media Release
By enrolling my child in BrainyBuilders STEM Hub programs, I acknowledge that I have read, understand, and agree to all enrollment forms and policies, including the Parent Agreement & Program Policies, Liability Waiver, Medical & Emergency Care Authorization, Student Behavior Expectations, and Photo, Video and Social Media Release. I understand that participation involves hands-on STEM activities and inherent risks, that all fees are non-refundable, and that BrainyBuilders reserves the right to modify or cancel programs as needed. I authorize BrainyBuilders STEM Hub and its staff to provide emergency medical care if necessary, agree to uphold behavior and safety expectations, and grant permission for my child’s image to be used for educational and promotional purposes unless otherwise indicated below. By submitting this enrollment, I accept full responsibility for my child’s participation and consent to all terms and conditions.
We respect your right to privacy. PLEASE CHOOSE ONLY 1*

I GRANT PERMISSION for BrainyBuilders to use photographs, videos, and other media involving my child(ren) for promotional, marketing, or educational purposes, including but not limited to, websites, brochures, social media platforms, and other public relations materials. I understand that these materials may be used in both print and digital formats.I DO NOT GRANT PERMISSION for BrainyBuilders to use photographs, videos, or any other media involving my child(ren) for promotional, marketing, or educational purposes, including but not limited to, websites, brochures, social media platforms, or other public relations materials.
Acknowledgement of Waivers & Expectations

First NameLast Name
Program Options
1. After-School Enrichment - $60/week (meets every Tues & Thurs), Best for kids balancing sports, dance, or other activities, *Most Popular*, Grades 3-6, Max 8
2. Discovery Saturdays - $50 (1/2 day), Flexible learning and fun. Best for parents who have limited flexibility during the week. Grades 3-7, Max 8
3. BrainyBots Saturdays - $30 (1/2 day) - $30, Flexible learning and fun. Best for parents who have limited flexibility during the week. Grades K-2, Max 8
4. Pathways Saturday Cohort - $85/month (meets 2nd & 4th Saturdays January - June only) Monthly commitment required and must have taken Discovery class. Grades 3-6, Max 8
Choose your program

Afterschool Tues/Thurs - FutureMakers (4:30 - 6:30) Grades 3-71/10: Engineering - BrainyBots (9am - 12pm) Grades K-21/17 & 1/31: Pathways Drones -(9am - 12pm) Grades 3-61/17: Discovery: Drones (1:00pm - 4:00pm) Grades 3-62/21: Pathways Drones (9am - 12pm) Grades 3-62/28: Pathways Drones (9am - 12pm) Grades 3-6
Payment

My Products*

Afterschool Tuesday/Thursday

$60.00 Quantity

Discovery 1/2-day - Saturday

$50.00 Quantity

BrainyBots 1/2-day Saturday

$30.00 Quantity

Pathways - Drones Cohort (2nd & 4th Saturday)

$85.00 Quantity

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

BrainyBuilders Registration Form

Waivers and Releases

Payment