Brinker Elementary - CraniaLogix - Fall 2016 (4th/5th grades)
Please fill in all of the following information to be registered for Brain Games, Session 4.
Space is on a first come, first served basis and is limited to the first 20 to sign up.
Signed Program Agreement and Release and payment by cash, check or PayPal is due on the first day of class.
Session dates: Thirteen classes (Tuesdays, Sept. 13, 20, 27, Oct. 4, 11, 18, 25, Nov. 1, 8, 15, 29, Dec. 6 and 13)
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Student's Name (first and last) *
Grade Level *
Teacher's Name *
Parent(s) Name *
Home Phone *
Cell Phone *
Phone number to reach parent during CraniaLogix class *
E-mail *
Please share any medical concerns we should know about. *
How student is getting home *
If your child is being picked up by an adult, please list those authorized to pick up. *
We would love to have another pair of hands in the classroom!  CraniaLogix is happy to provide a 50% discount to a parent who is willing to commit to attending and helping as needed at all classes for the session.  If you are interested, please leave your name and email address in the space provided, and we will contact you with more details.
I understand that I will receive an email upon registration either confirming space in the class or that my child is on a wait list.  Space is limited to the first 20 registrants.  Payment information and other class information will also be provided in that confirmation email. *
My child wants a CraniaLogix t-shirt to wear on class days!
T-shirts are $10 and can be paid for via PayPal, check or cash.
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