Blooming Einsteins Online Registration

Registration

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Welcome to Blooming Einsteins! Please complete the following registration form.

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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*

Home or 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* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

School*

Grade Level for 2020-2021 school year*

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

Allergies*

Medications*

Enroll in Classes

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Maximum number of enrollments reached.
Please use the parent portal to enroll in an unlimited number of classes.

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

School*

Grade Level for 2020-2021 school year*

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

Allergies*

Medications*

Enroll in Classes

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Sorry! You can’t enroll because of Class Age Requirements

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Maximum number of enrollments reached.
Please use the parent portal to enroll in an unlimited number of classes.

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

School*

Grade Level for 2020-2021 school year*

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

Allergies*

Medications*

Enroll in Classes

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #1 *

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Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

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Maximum number of enrollments reached.
Please use the parent portal to enroll in an unlimited number of classes.

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

School*

Grade Level for 2020-2021 school year*

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

Allergies*

Medications*

Enroll in Classes

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #1 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #2 *

Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

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Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #8 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #9 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #10 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #11 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #12 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #13 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #14 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #15 *

Maximum number of enrollments reached.
Please use the parent portal to enroll in an unlimited number of classes.

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

School*

Grade Level for 2020-2021 school year*

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

Allergies*

Medications*

Enroll in Classes

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #1 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #2 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #3 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #4 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #5 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #6 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #7 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #8 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #9 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #10 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #11 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #12 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #13 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #14 *

Sorry! You can’t enroll because of Class Age Requirements

Select Schedule #15 *

Maximum number of enrollments reached.
Please use the parent portal to enroll in an unlimited number of classes.

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Required Policies and Agreements

Agreement

Agreement and Acknowledgement: I have read the above information provided in the Parent Handbook. I understand and I agree to follow all policies and procedures of Blooming Einsteins.

I've read the above and agree.

Release

I acknowledge that I have voluntarily chosen to register the minors listed on this registration form to participate in the above-referenced activities including field trips, vehicle/foot travel, outdoor/indoor play, outdoor/indoor activities, bounce house use and have full knowledge of the risks that these activities present, including travel to, participation in, and returning from the activity. I understand that by being permitted to participate in activities, in lieu of gross negligence by Blooming Einsteins, I agree to assume any and all risk of injury or death. I further understand and agree to assume responsibility for all risk of theft, loss or damage of personal property which occurs at any time. I understand and agree that I have carefully read this agreement and fully understand all of its terms and conditions. I understand that this is a release of liability which could legally prevent me from filing suit or making any other claim for damages. By acknowledging and agreeing to this waiver, I am entering into this agreement freely and voluntarily.

I've read the above and agree.

Acknowledgement

Blooming Einsteins provides as many fun and enriching activities as possible. This may include field trips to various destinations around the Fort Mill, SC - Charlotte, NC areas. Blooming Einsteins will arrange all transportation to and from each field trip and prior notice will go out to all parents. I give my child permission to walk to points of interest in close proximity to the program site under Blooming Einsteins supervision.

I've read the above and agree.

Photo/Media/Social Release

Blooming Einsteins provides as many fun and enriching activities as possible. This may include field trips to various destinations around the Fort Mill, SC - Charlotte, NC areas. Blooming Einsteins will arrange all transportation to and from each field trip and prior notice will go out to all parents. I give permission to have my child appear in any Blooming Einsteins coverage or brochures.

I've read the above and agree.

Behavior Policy

Behavior Policy Students will be required to abide by the Blooming Einsteins policies, and procedures, to ensure that each participant remains safe. We are a non-corporal punishment facility. In most cases when discipline is needed, we believe in redirection, or diversion. If the previous measures become ineffective, we will notify parents. If poor behavior continues, a conference with parents will be held to discuss the behavior, and positive methods, to promote more appropriate behavior at our school. If behavior does not improve, as a last resort, the student may be removed from the program. Fighting, of any kind, will not be tolerated, and may result in suspension. This may include intentional hitting, punching, kicking, biting, swearing, or bullying. Gossiping about students, and/or their families, is also prohibited, and may result in suspension. We can assure you that safety, of all of our students, physically, emotionally, and socially, is our primary goal.

I've read the above and agree.

Withdrawal/Cancellation Policy

Early Withdrawal / Cancellation Policy A two-week notice of withdrawal in writing is required for all children. Failure to provide a withdrawal notice will result in your account being charged for the tuition of the registered week. Blooming Einsteins reserves the rights to discharge any child/family for failure to pay tuition or for unmanageable and disruptive behavior that brings harm or continued disruption to the staff and other children.

I've read the above and agree.

Transportation Policy

Blooming Einsteins provides as many fun and enriching activities as possible. This may include field trips to various destinations around the Fort Mill, SC - Charlotte, NC areas. Blooming Einsteins will arrange all transportation to and from each field trip and prior notice will go out to all parents. I give my child permission to leave the program site for trips in a school activity bus or other transportation to off-site locations and enrichment programs.

I've read the above and agree.

Field Trip Policy

Blooming Einsteins provides as many fun and enriching activities as possible. This may include field trips to various destinations around the Fort Mill, SC - Charlotte, NC areas. Blooming Einsteins will arrange all transportation to and from each field trip and prior notice will go out to all parents. I hereby give my child permission to participate in all activities of the program, including field trips.

I've read the above and agree.

Insurance Policy

Insurance Coverage: Insurance coverage is a requirement to participate in any Blooming Einsteins Program. I, the undersigned, Parent or Legal Guardian of the registered participant, certify that the named participant is covered by an insurance program with the company provided above, which will compensate for injuries incurred while participating in Blooming Einsteins activities.

I've read the above and agree.

Participation Policy

Agreement of Participation: I verify that my child is in good mental and physical health, and may participate in the Blooming Einsteins After School Program. I also verify that my child's immunization shots are up to date. I give permission to authorize emergency care to my child in the event that neither the first or second guardians can be contacted. I prefer my child be transported to the hospital provided above, in the case of an emergency.

I've read the above and agree.

Deposit Fees

Summer Camp Deposit fee is $ 35.00 per week -
After School Deposit fee is $93.00 and will serve as the first week's tuition payment. Tuition will be drafted biweekly.

The Deposit Fee will be drafted immediately to hold your child's spot. These fees are NON-REFUNDABLE.

I've read the above and agree.

Payment Policy

Tuition Balance is due weekly on the Friday before the upcoming week of Summer Camp.
After School tuition will be drafted biweekly.

Decline Fee of $25.00 for all returned payments.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

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 *