for Fast Braiin Learning Academy
offered through Growing Child Pediatrics PA

Full payment is due prior to enrollment. ($250/week 9AM-5PM; $185/week 9AM-1PM)

Child’s Name (Last, First, MI)

Address (Street, City, State, Zip)

Track #

Track 1 Camps:

Track 2 Camps:

Track 3 Camps:

Track 4 Camps:

Child resides with:

Custody Concerns?

Email address
Employer Work Phone Cell phone

Email address
Employer Work Phone Cell phone

Emergency Contacts (name/ relationship to child/phone #)

List others who have permission to pick up the camper. They must show photo ID upon arrival.

Camper’s interests

If there are issues, what are the triggers we need to be aware of?

Please use this space to tell us anything else you would like us to know about your child.

Parent/Guardian Permission: As a legal guardian I give permission for the registrant to participate in all camp activities. I understand and agree to cooperate with all regulations. I will not allow registrant to attend if not in good physical condition. In an emergency, when the undersigned or other person named cannot be reached, I give permission for the camp authorities to take any emergency measures deemed appropriate. It is understood that all reasonable efforts will be made to contact the parent/guardian. I understand that when participating in Fast Braiin camp activities the registrant may be photographed for print, video or electronic imaging. I understand that the images may be used in promotional and fundraising materials, news releases and other published formats, and will be the sole property of Fast Braiin.

I, the undersigned parent or guardian, hereby consent to my child, who is years of age, participating in the activities connected with the trip to and from and the time at the Fast Braiin Learning Academy. I certify that my child is able to participate in these activities. If my child has a medical condition which may be relevant to a physician in the event of an emergency, I have listed them aobve. If I cannot be reached within a reasonable period of time, I hereby authorize an adult at the Fast Braiin Learning Academy to make emergency medical decisions regarding my child. If there are any activities I do not want my child to be involved in, I have listed them above. I understand that my child may be dismissed for breaking any rules or disobeying. I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby agree to hold the Fast Braiin Learning Academy, Growing Child Pediatrics, PA, and its agents and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future with the activity or participation in any other associated activities. I expressly agree that this release, waiver and indemnity agreement is intended to be broad and inclusive as permitted by the law of the of the State of North Carolina and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto, and the terms of this release are contractual and not a mere recital. I further state that I HAVE CAREFULLY READ THE FORGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and understand.

Registrant Be photographed for Fast Braiin publicity purposes.

Fast Braiin and the Fast Braiin logo are trademarks of Fast Braiin, LLC
Copyright © 2012 by Fast Braiin, LLC. All rights reserved.