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2014-2015 REGISTRATION FORM
Thank you for joining
Please fill out a separate form for each student!
I greatly appreciate you taking the time to print clearly, so my office staff and I can read your information. Thank
you!
Class enrolling in (may list more than one)_______________________________________________________________
Student's Name_______________________________________________ Age_______ Birth Date_________________
Student’s School ________________ Teacher_________________________________ Grade_____ Classroom______
Best phone number to reach, if there is an issue with pick-up___________________________________________
Mother’s Name____________________________________ Father’s Name____________________________________
Cell Phone________________________________________ Cell Phone_______________________________________
Home Phone______________________________________ Home Phone______________________________________
Work Phone______________________________________ Work Phone_______________________________________
E-Mail__________________________________________ E-Mail___________________________________________
Address___________________________________________________________________________________________
City________________________________________________ State________ Zip________________
Please provide two emergency contact names (Not Parents):
1) Name_______________________________________________ Phone____________________________________
Relationship____________________________________ Cell____________________________________
2 Name_______________________________________________ Phone____________________________________
Relationship____________________________________ Cell____________________________________
Doctor/Pediatrician________________________________________ Phone____________________________________
Dentist________________________________________ Phone____________________________________
Insurance Company_________________________________________________
Please list any medical conditions or allergies (we may have snack during club time):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POLICIES

All members are encouraged to attend weekly classes because each class builds on previous classes.

Occasionally school may have emergencies, unplanned school closures, or mis-schedulings. These can be due to
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natural disasters, imminent thread, drills, or simple human error. In the event of such a problem, we do not provide
refunds/reschedule unless time permits.

Please note, whenever school is out early or class is canceled, we will not hold our normal meetings. Please see your
class schedule for further information.

If your child is ill, please do not send them to attend sick.

Parent/Guardian is required to pick up child.

If there are concerns with the class, please contact the instructor so we can best address them as promptly as possible.

There may be filming/photography of speeches/debate/performance. These will be used for teaching, evaluating
performance, reviewing technique, or promotional purposes.

Please send a note, if someone else besides the parent is picking up your child. If this person(s) will be consistently
picking up your child, please fill in the following:
Name______________________________________ Cell_____________________ Phone_____________________
Name______________________________________ Cell_____________________ Phone_____________________
Name______________________________________ Cell_____________________ Phone_____________________

Upon rare occasions, I may need to cancel/reschedule a class. In that event, I will work with the school to either
reschedule class, or have the children attend another class at their level whenever possible.
THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS Brier Buchalter's academic
programs for Kids, its owner or if applicable its directors, officers, employees or agents and each of them from any loss,
liability damage, expense (including reasonable attorney’s fees) that Brier Buchalter's academic programs, its owner or if
applicable its directors, officers, employees or agents may incur due to the presence of the undersigned or Participant in or
about the Brier Buchalter's academic programs, premises or by any participation in any program or activity offered by or
affiliated with Brier Buchalter's academic programs, whether or not caused by the negligence of Brier Buchalter's
academic programs, its owner or if applicable its directors, officers, employees or agents.
Please make payments out to Brier Buchalter and include them with your registration forms, which may be dropped off at
the first class meeting.
I have read and agree to abide by the policies for Brier Buchalter's academic programs.
Parent / Guardian Signature_____________________________________________ Date__________________________
Siblings not attending Brier Buchalter's academic programs (optional):
Name__________________________________________ Name_____________________________________________
Birth Date______________________ Age_________ Birth Date______________________ Age_________
Thank you for choosing to participate in Brier Buchalter's academic programs. I am looking forward to a
wonderful year of learning, growing, and helping others do the same!
Brier Buchalter