Braingineers Lab Online Registration

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Welcome to BRAINGINEERS LAB! Please complete the following registration form.

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Referral Information

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Family Information

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Home Address*

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Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

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Contact #1

Mother's / Guardian 1 First Name*

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Contact #2

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Student #1

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Student #2 (Show-Hide Details)

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T-shirt size*

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Student #4 (Show-Hide Details)

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Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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T-shirt size*

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Student's First Name*

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Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

T-shirt size*

School*

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Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

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