Redlands After School Program Registration
  1. Please complete form and Submit
  2. Please select Program Site(*)
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  3. Please Check(*)
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  4. Student First Name(*)
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  5. Student Last Name(*)
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  6. Student Middle Initial
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  7. Gender(*)
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  8. Primary Language
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  9. Qualify for Free or Reduced Lunch
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  10. Please select if applicable
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  11. Date of Birth(*)
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  12. Grade
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  13. PARENT - GUARDIAN
  14. Parent First Name
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  15. Parent Last Name
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  16. Relationship(*)
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  17. Street Address(*)
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  18. City
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  19. State
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  20. ZIP(*)
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  21. Home Phone
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  22. Cell Phone
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  23. Email Address(*)
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  24. Does this Student have an IEP?
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  25. Is there a Custody Concern?
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  26. Is there a Court Order regarding this Student?
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  27. MEDICAL INFORMATION
  28. Allergies
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  29. Doctor, Insurance Company and Policy
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  30. AUTHORIZED PICK-UP PERSONS
  31. I Authorize the following Persons to Pick Up my Child from Program (List Name, Phone and relationship)
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  32. In case of emergency and when I cannot be reached, I authorize Creative Brain® Learning to implement standard emergency procedures, including paramedic, hospital and physician care for student above. I, herewith, authorize any emergency treatment deemed necessary by the physician/medical advisor in charge, and agree to hold Creative Brain® Learning and its agents harmless from any and all claims.(*)
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  33. I hereby agree to allow the student named above to be included on any audio visual and photographic recordings as part of the program, and as part of documentary, archival, promotional and other purposes. I. herewith, relinquish any and all demands for compensation whatsoever arising from the use of such recordings. I also release, discharge, and agree to hold harmless Creative Brain® Learning and its agents from any liability for the preparation, distribution and use of photos, videos and/or sound recordings whether they include my child listed above or not.
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  34. I authorize CBL staff to have access to my child’s grades/report card. I authorize my child to participate in evaluations, survey, and questionnaires as part of the program. By signing below I agree to abide by all policies and rules, and confirm that any and all information provided above is complete and accurate. If any information changes, I agree to provide an updated Student Registration form.(*)
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  35. Please enter the code you see
    Please enter the code you see
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  37.