Registration K – 2nd

Saturdays, 10 am – 11:15 am

Parent/Guardian 1 *

First

Last

Email *

Phone

Parent/Guardian 2

First

Last

Phone

Child Information *

First

Last

Age *

Grade *

School *

Emergency contact 1 *

First

Last

Phone *

full Parent/Guardian EpiPen),

Emergency contact 2

First

Last

Phone

Has your child attended a Neuro Ninjas session before? *

If yes, when and where?

Please list any medical condition we should know about, such as allergies (include use of EpiPen), epilepsy, etc *

Authorized pickup: Please list the full names of all authorized people *

How did you hear about us *

Media Release: I grant LodeLu permission to use photos/videos of my child for website and marketing purposes. *

Equipment Care Agreement: *

I understand that students will be using specialized neuroscience equipment (SpikerBot prototypes) and electronics (computers and iPads). While normal wear and tear is expected, parents may be responsible for damages caused by intentional misuse.