Blooming Einsteins Online Registration

Registration

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Welcome to Blooming Einsteins! Please complete the following registration form. Should you have any questions, please do not hesitate to reach out.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Account Information

Account Name Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Name, Phone #, Relationship*

Contact #1

Contact #1 First Name*

Last Name *

Type

How Can We Contact You?

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Current Grade Level*

Anything we should know about your child to best accommodate them?*

Allergies*

Medications*

Grade level for 2022-2023*

Grade level for 2023-2024*

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Current Grade Level*

Anything we should know about your child to best accommodate them?*

Allergies*

Medications*

Grade level for 2022-2023*

Grade level for 2023-2024*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Current Grade Level*

Anything we should know about your child to best accommodate them?*

Allergies*

Medications*

Grade level for 2022-2023*

Grade level for 2023-2024*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Current Grade Level*

Anything we should know about your child to best accommodate them?*

Allergies*

Medications*

Grade level for 2022-2023*

Grade level for 2023-2024*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Current Grade Level*

Anything we should know about your child to best accommodate them?*

Allergies*

Medications*

Grade level for 2022-2023*

Grade level for 2023-2024*

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

eCheck/Bank Draft

Bank Name *

Account Type *

Your Account Name * (Your name on your bank statement)

Bank Routing Number * (9-digit number)

Account Number *

Registration

Referral Information

Account Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

eCheck/Bank Draft

Required Policies

(Show-Hide Details)