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Club Name______________________________ Fall___ Winter___ Spring___
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!
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__________________
Siblings attending Brier Buchalter's academic programs:
Name__________________________________________ School___________________ Grade___ Age___
Name__________________________________________ School___________________ Grade___ Age___
Name__________________________________________ School___________________ Grade___ Age___
Please provide two emergency contact names (Not Parents):
1) Name________________________________________________ Cell____________________________
Relationship____________________________________ Phone___________________________________
2) Name________________________________________________ Cell____________________________
Relationship____________________________________ Phone___________________________________
Please list any medical conditions or allergies (we may have snack during club time):
_________________________________________________________________________________________
_________________________________________________________________________________________
Doctor/Pediatrician_________________________________________ Phone__________________________
Dentist_______________________________________________ Phone______________________________
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Club Member’s Name___________________________________________
Insurance Company____________________________________________________
POLICIES:

All members are encouraged to attend weekly classes, because each class builds on previous classes.

If your child will be absent, please notify the instructor via email, call or text @ (408) 460-7810.

If your child is ill, please do not send them to attend sick.

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.

Occasionally school may have emergencies, unplanned school closures, or mis-schedulings. These can be
due to 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.

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.

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.

Parent/Guardian is required to pick up child or give written permission for them to walk/bike home.
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________________
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.
Completed registration forms may be emailed or brought to the first meeting along with the class payment.
Please make checks out to Brier Buchalter. If you are dropping off the completed registration, please be sure
to email your child’s name, school and grade, to ensure that they will be added to the class roster. Space is
limited!
I have read and agree to abide by the policies for Brier Buchalter's academic programs.
Parent / Guardian Signature____________________________________________ Date_________________
Thank you for choosing to participate in Brier Buchalter's academic programs. I am looking forward
to a wonderful year of learning and growing, while helping others do the same!
Brier Buchalter
(408) 771-2904
brierbuchalter@gmail.com