FITBRAINIACS

AFTER-SCHOOL REGISTRATION

SPRING 2019

Please select your child's school

Discounts

Early Bird pricing - $10 off our usual eight-week price - will be automatically applied through March 10, 2019.

Active duty and veteran military = $10 off
First responders = $10 off
Educators = $10 off

These discounts may be selected below and may not be combined.

Registration Options

Full Spring Pilot - Tuesdays/Thursdays - 3/19-5/16 (16 sessions) ($95.00)
Activity Theme: World Games

FitBrainiacs meets twice each week (Tuesday/Thursday) from 2:15-3:15
Individual Weeks/Sessions ($0.00)
Choose your preferred weeks/sessions below.

I am interested in volunteering to help with class in exchange for my child's free enrollment.

You may choose individual sessions or weeks for which you are available. Contact us for more information.

Parent Information

Parent/Guardian's Name

Phone Number

Zip Code

Child Information

Child's Name

Child's Date of Birth

Child's Gender

Male
Female

Who is your child's teacher?

How will your child(ren) be getting home after class?

Other:

Does your child have any medical/behavioral issues that may impact their ability to succeed in FitBrainiacs?

Emergency Information

Emergency Contact (If parent/guardian cannot be reached):

Emergency Contact Phone Number:

Relationship to child:

Health Insurance Provider:

Insurance Policy Number:

Hospital Preference:

Child's Doctor:

Doctor's Phone Number

Photo Consent*

By registering, I am giving my permission for my child/children to be photographed during FitBrainiacs classes and events. I understand that these photographs may be used in marketing materials through print, video, and online channels. Please contact us with any questions.

Terms, Conditions, and Waivers

I, the undersigned, agree to the terms above.

E-Signature Disclosure*

By signing this document, you give your consent to electronic disclosures and to the use of electronic signatures. This CONSENT informs you of your rights when receiving legally required disclosures, notices and information from us and when using electronic signatures in connection with your transactions with us. By consenting to the electronic delivery of disclosures, you agree that we may provide electronically any and all communications to you. You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time.

FitBrainiacs Merchandise

Each child will receive a FREE FitBrainiacs water bottle and sport towel with their first full six- or eight-week enrollment. These items are available for purchase below for students registered for individual days/weeks or if you need a replacement.

FitBrainiacs Water Bottle
$5.00 ea.
Add
FitBrainiacs Cooling Towel
$5.00 ea.
Add

Running Total

$0.00

Coupon Code

Discounts

Educators - $10 off
Teachers/Administrators/Support Staff (May not be used with early bird pricing)
First Responders - $10 off
Police/Fire/EMT (May not be used with early bird pricing)
Military - $10 off
Active Duty/Veteran Servicemembers (May not be used with early bird pricing)

Please note: educator, first responder, and military discounts may not be combined and may not be used on top of early bird pricing.

Credit Card Processing Fee

$4.00

Note: Processing fee may be avoided with offline check/cash payment. Please select the Offline option during billing and contact us directly to make payment arrangements.

Total

$4.00

Billing Information

Name

Payment Method

Credit Card
Offline

Credit Card

Visa
Mastercard
American Express
Discover

Phone Number

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