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Smart Brain International

ENROLLMENT APPLICATION

STUDENT'S NAME
Last:
First:
DATE OF BIRTH
/ /
AGE
GRADE
GENDER
BOY
GIRL
SCHOOL NAME
STREET ADDRESS
CITY
STATE
ZIP
HOME PHONE NUMBER
MOTHER:

FATHER:
PARENT EMAIL ADDRESS (TO SEND UPDATES)
MOTHER:

FATHER:
HOW DID YOU HEAR ABOUT SMART BRAIN INTERNATIONAL?

AD WEBSITE FLYER FACEBOOK

OTHER:

FRIEND NAME:

PHONE #:

CENTER THEY ATTENDED:

MOTHER'S NAME:

CELL #:

OFFICE #:
FATHER'S NAME:

CELL #:

OFFICE #:

CHILD RELEASE

Who else besides parents will be allowed to pick up your child? If not filled out, we will only release to parents


NAME:

RELATION TO STUDENT:

HOME #:

CELL #:

OFFICE #:


NAME:

RELATION TO STUDENT:

HOME #:

CELL #:

OFFICE #:


NAME:

RELATION TO STUDENT:

HOME #:

CELL #:

OFFICE #:

GENERAL DISCLOSURE

Please list any other information you would like us to know about your child:


IN CASE OF EMERGENCY

(other than parents)

NAME
RELATIONSHIP
HOME PHONE
MOBILE PHONE
NAME
RELATIONSHIP
HOME PHONE
MOBILE PHONE
PHYSICIAN NAME
PHONE NUMBER
OTHER INFORMATION

HEALTH & ALLERGY HISTORY

List any allergies or restrictions to foods (nuts, milk, meat, etc) and to any medications ? If none, please write N/A

PERMISSIONS

"In the event I cannot be reached for emergencies at the time of illness or accident, I hereby authorize Smart Brain International to take my child to a physician, hospital or clinic, and I give my consent for any necessary emergency care . Any expense that may arise from this care will be the responsibility of the child’s parent/legal guardians."

SIGNATURE

PRINT NAME

I understand from time-to-time, Smart Brain International will take general photo or video of its classes. Should my child appear in photo and/or video, I grant Smart Brain International to use such photographs and/or video for purposes, such as: publicity, illustra-tion, advertising, web content, and the like without requiring any further permissions from me. I further agree ad understandthat any photographs and/or video are the property of Smart Brain International.

SIGNATURE

PRINT NAME

Smart Brain International

ENROLLMENT APPLICATION

At Smart Brain International, we strive to deliver the best possible service in education without ever compromising on our company values. In order to achieve this and to be fair to all parents and students, we will require a credit card to be kept on hand for three different reasons: 1-, to allow a 4-month commitment to our program; 2–after the 4-month commitment, to serve as a form of payment for unpaid invoices after 30 days; 3–to give you the freedom of remembering yet another bill and allowing us to automatically charge your card below on the first, or thereabouts, of every month.

Yes, I accept the terms for the 4-Month Commitment (mandatory) Unpaid Tuition Payments(mandatory) Automatic Monthly Billing Option (optional)
You will be charged monthly, but will commit to 4 months of enrollment. If your child does not complete the 4 month commitment period then your credit card, indicated below, will be charged the difference between number months attended less the 4 months. If my credit card cannot be charged, then I am personally responsible for this amount. If I change or cancel my credit card or my billing address, I will immediately inform Smart Brain International. If your child does not complete the 4 month commitment period then your credit card, indicated below, will be charged the difference between number months attended less the 4 months. If my credit card cannot be charged, then I am personally responsible for this amount. If I change or cancel my credit card or my billing address, I will immediately inform Smart Brain International. By signing below, I agree to have my credit card charged monthly for the classes I have enrolled in. This authorization will remain in effect until I notify Smart Brain International in writing 30 days in advance to stop this automatic payment option

Sign

Print

Sign

Print

Sign

Print

Date

Date

Date

MY CARD IS (SELECT ONE) VISA MASTER CARD AmEx Discover
THE NAME ON THE CARD (EXACTLY AS IT APPEARS ON THE CARD)
BILLING ADDRESS CARD NUMBER
STREET
CITY STATE ZIP
EXPIRATION DATE: MONTH YEAR
Please Sign Please Print Name
Student Name(Print) Enrollment Date Card Information (type name, #, exp, signature)Verified By
__________________   __________________
Sign(office personnel)  Print (office personnel)
Release of Liability for Student Drop-off & Dismissal

I understand that I am requested by Smart Brain International to drop-off & pick -up my child to and from inside the center for safety reasons.

However, I (parent / guardian) give Smart Brain International permission to dismiss my child and leave the Smart Brain International center without being picked-up by a parent, guardian, or authorized person as listed on the enrollment application.

By allowing my child to arrive at the center or to leave on their own, I hold harmless Smart Brain Interna-tional, Smart Brain International Franchise Corp, its employees, affiliates, or any person and entity in con-nection with company from any liabilities of any nature whatsoever that may arise.

Sign—Parent / Guardian

Print -Parent / Guardian

Student Name

Smart Brain International

ENROLLMENT APPLICATION

VALID AS OF September 1, 2012

By adhering to the policies below, you allow us bring to you a better value, quality, and fairness to our students and you, our parent. Although the below policies will be strictly enforced; should you have any special circumstances, please bring it to our attention immediately. We thank you for you timely attention to this matter.
Refund Policy Monthly Tuitions and Registration Fee’s are NOT refundable for ANY of our programs for ANY reason
Make-Up Policy 1-Make-up classes must be made-up by the end of the following month. Unused make-up’s cannot be rolled over to future dates. No exceptions.
2–You MUST be fully paid and currently enrolled to redeem make-up classes. You absolutely may not redeem make-up’s if you are “on break”, dropping out, or the like.
3–If you cannot attend a make-up class for any reason whatsoever the class cannot be rescheduled.
4–Make-up classes are NOT guaranteed. We will allow make-up ONLY if there is sufficient room in a class. Even under this stipulation, you have only to the end of the following month to complete the make up.
5-When enrolled in the Abacus combo program, there are NO make-up’s for the Smart Plus enrichment class: Math, English, Social Studies, Science. No exceptions.
5 week 1-In a 5 week month, the 5th class is considered a free class. Therefore, a missed 5th-wk class cannot be made-up. There will be no exceptions.
Payment Policy 1-All tuitions are due by the first class of the month. Payments received after the 10th of the month will be automatically assessed a $5 late fee (per family, not child).
2-All material fee’s are due upon receipt of a new book and / or materials.
3 -Tuition payment cannot be offset by any accumulated make-up classes. There will be no excep-tions.
Re-Registration Any consecutive leave of 60 days or more will result in a new Registration Fee to be paid upon returning to any program.
Dismissal Policy We will release your child ONLY to the parents or child release names listed on the enroll-ment form. Children under 18 must be picked-up by inside the center and will not be allowed to leave by themselves out the front door or from any upper level floors, unless a release form has been signed.
Student's Name:
Parent's Name:
Parent's Signature:
Date:

Smart Brain International

Course Selection Sheet

Student:
Description / Program Price Enroll Date Un-enroll Date Signature
Abacus Mental Arithmetic:
Standard $199.00
Sibling Discount $190.00
Pre-Smart Brain $149.00
Private $249.00
K -5 Enrichment with Abacus :
Math $90.00
English $90.00
Social Studies $90.00
Science $90.00
K -5 Enrichment without Abacus :
Math $100.00
English $100.00
Social Studies $100.00
Science $100.00
K -5 Home Work Help :
With no other program enrollment $150.00
With any other program enrollment $150.00
Advanced Tutorials:
Standard –3 hrs/wk: 1 ½ hrs Math + 1 ½ hrs English $275.00
Sibling Discount $250.00
Individual Subject –1 ½ per week either Math or English $199.00
Test Prep:
Standard –12 week session –SAT, ACT, SSAT, etc. $825.00
Smart Core:
Math / English / Science / Social Studies –k to 5 $360.00
Non-Academic Enrichments:
V.S.U. -Vocabulary, Spelling, Usage $150.00
Brain Builders -Public Speaking, Chess, Robotics, Complex Puz-zles $100.00
Chess $80.00
Camps & Workshops:
Summer / _____________Camp
____________________ Workshop
Fee’s & Totals
Materials fee payable upon issue of new materials $20-$30
Late Fee applies to tuitions paid 10 days after due date $10