Brandon House Enrollment Form

Choose a BH Program

Currently, all our Grant Funded Programs are at No COST to participants. Please select the Brandon House program from the drop down list that you wish to enroll in.

What program(s) would you like to enroll in? (Click all that may apply)

Select the program the student is seeking enrollment. Please be sure to check applicable programs. Pay attention to ages, grades, or schools associated with program if listed. Only 1 program can be checked per applicant

DreamStarters (Accepts DHS Vouchers) Ages 6 - 12
Fall In After School Program (Ages 13 - 18)
Creative Expressions (Can only Enroll During Special Enrollment Times - Do Not Check unless advised)
BOXed-In Violence Intervention Program

DREAMSTARTERS REQUIREMENT

If you or someone you know are interested in registering for the DreamStarters Program, you will have to complete two assessments which are listed below BEFORE submitting your application. If you DO NOT complete the assessments, your application will be considered incomplete. If you would like to learn more about our programs, click here.

Assessment #1

Assessment #2

Participant Information

Student Name

Please enter the name of student who would be enrolled in Brandon House Programs.

First Name *

Middle

Last Name *

Student ID

Date of Birth

Month

Day

Year

Age (Required)

Gender (Required)

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Email (Required)

Student Phone (Required)

Who does student live with? (Required)

If "Other" was selected, please indicate who student lives with below.

Race (optional)

If "Other" was selected, please indicate the Race of student below.

Parent/Guardian Information

Must be completed by Parent/Guardian if the participant is under the age of 18. Otherwise, information can be completed by the participant.

Parent/Guardian Name

Prefix

First Name *

Middle

Last Name *

Suffix

Relationship to Participant (Required)

Marital Status (Required)

Parent/Guardian Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Home Phone (Required)

Email (Required)

Number in Household (Required)

Place of Employment (Required)

Work Phone

ext Extension

Emergency Contact Information

Emergency Contact #1

Prefix

First Name *

Last Name *

Relationship to Student (Required)

Contact Number (Required)

Emergency Contact #2

Prefix

First Name *

Last Name *

Relationship to Student (Required)

Contact Number (Required)

School Information

School District

If "other" was chosen, please indicate school district.

School Name

Grade/Education Level

indicate the highest level education attained OR the grade in which participant is enrolled.

Home Room Teacher

School Counselor

Participant Health & Safety Information

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Personal Physician

Physician Location

Date of Last Check-Up

Month

Day

Year

Does your student have health insurance?

Does your student take any medication?

Any known allergies?

If yes, indicate what kind of allergies your student has.

Food Allergies
Bee Stings
Trees, Grass, Pollen
Animals

Provide any details about allergies.

Indicate what kind of food or animal allergies your student may have.

Does your student carry an Epi-Pen?

Has participant ever had a Psychological Assessment?

If yes, indicate the date of assessment.

Month

Day

Year

Indicate location/agency assessment was conducted.

Does your student have a physical disability?

If yes, indicate what kind of physical disability.

Does your student have any chronic health problems?

If yes, please provide detail on what kind of chronic health problem.

Does your student attend counseling sessions?

If yes, indication the location/agency that conducts sessions.

Is your student enrolled in residential treatment?

If yes, please indicate location/agency enrolled.

Has your student ever been diagnosed with any of the following?

ADD
ADHD
Diabetes
Asthma

please indicate date of diagnosis.

Month

Day

Year

Does your student have any dietary restrictions?

If yes, please indicate the restrictions.

PARENTAL MEDICAL & HOLD HARMLESS CONSENT

Knowing there is a certain amount of risk involved in even the simplest of program activities, I give my permission for my child to participate in Brandon House Cultural & Performing Arts Center, [herein referred to as Brandon House] activities and programs. I accept responsibility in the unlikely event that an accident might take place and I understand that Brandon House is not liable for personal injuries and/or property damage to my child.

I understand that in the unlikely case of an accident for my child I am solely responsible for the cost of health care for my child, even as a result of my child’s participation in Brandon House programs or activities.

I hereby consent to my child being given emergency treatment by a physician or hospital in case of an accident due to his/her taking part in Brandon House programs. I understand that Brandon House does not cover my child with any primary medical insurance coverage and that the parent/guardian is financially responsible for any treatment provided.

I hereby agree to hold harmless Brandon House, members of its board, staff, and authorized volunteers for accidental injury to my child or damage to my child’s property. I give permission for my child to participate in all program activities, and do forever release Brandon House and its members of the board, staff, volunteers and agents from any and all actions, all known and unknown personal injuries or property damage to my child arising out of any and all Brandon House activities. I also forever release Brandon House of any and all claims or right of action for damages which my child has or hereafter may acquire as a result of participation at Brandon House.

Do you consent?

Checking here indicates that you agree to consent with the above information and will electronically sign your name below.

Sign Full Name Here

FIELD TRIP PERMISSION

Occasionally, your child may be invited on a field trip as part of the after school or summer program. In the event of a field trip, you will receive detailed information about the proposed trip. By signing electronically below, you give Brandon House permission to transport your child to and from any field trip opportunity.

Do you consent?

Checking here indicates that you agree to consent with the above information and will electronically sign your name below.

Sign Full Name Here

COVID-19 WAIVER RELEASE

In consideration of my child, being allowed to participate in any way in Brandon House related program events and activities, the undersigned acknowledges, appreciates, and agrees that:

Given the contagious nature of the Coronavirus/COVID-19, I cannot guarantee the risks of injury and illness (ex:
communicable diseases such as influenza and COVID-19) to my child from the activities involved in Brandon House’s programs, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce these risks, the risks of serious injury and illness do exist; and,

For my child, who will be a participate in Brandon House Programs, knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases of others, and assume full responsibility for my child’s participation in Bandon House’s programs; and,
I, for myself, nor any member of my family, including my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin willingly agree to comply with the program’s stated and customary terms and conditions for participation; and,
I hereby release and hold harmless Brandon House Cultural & Performing Arts Center its board of directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releasees”), with respect to any and all injury, illness, disability, death or loss or damage to person or property incident to my child’s involvement or participation in Brandon House’s programs, whether arising from the negligence of or otherwise, to the fullest extent permitted by law.
I, for myself, nor any member of my family, including my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, hereby indemnify and hold harmless all the above Releasees from any and all liabilities incident to my involvement or participation in Brandon House’s programs, even if arising from their negligence, to the fullest extent permitted by law.
I, the parent/guardian, assert that I have explained to my child the risks of the activity and it is his/her responsibilities for adhering to the rules and regulations, and that my child understands this agreement.
I attest that:

Participant's Name

First Name *

Last Name *

Please read and check mark the following statements before electronically signing below:

My child is not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
My child has not traveled internationally within the last 14 days.
I do not believe my child has been exposed to someone with a suspected and/or confirmed case of COVID-19.
My child has not been diagnosed with COVID-19.
I do not believe my child has been exposed to someone with a suspected

The undersigned, on his/her behalf and on the behalf of the participating child, hereby releases, waives, discharges and covenants not to sue Brandon House Cultural & Performing Arts Center, its directors, officers, employees, volunteers and agents from all liability to the undersigned or such participating children and all personal representatives, assigns, heirs, and next of kin of the undersigned or such participating children for any loss or damage, and any claim or demands on account of any property damage or any injury to, or an illness or the death of, the undersigned or such participating children ( or any person who may contract COVID-19, directly or indirectly, from the undersigned or such participating children) whether caused by the negligence, active or passive, of Brandon House or otherwise while the undersigned or such participating children are in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with Brandon House.

I, FOR MYSELF, MY SPOUSE, AND CHILD/WARD, HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Sign Full Name Here (Required)

PARENTAL RELEASE

Please read and check mark the following statements before electronically signing below:

I hereby certify that my application contains no false information and is complete, truthful, and accurate to the best of my ability.
I understand that applications for this program, sponsored by Brandon House Cultural & Performing Arts Center, are accepted without regards to sex, race, color, national origin, physical/mental disability, religion, or political affiliation.
I understand that Brandon House will have publicity photos/videos taken during programming for use in local media, brochures, Brandon House’s Facebook page and on its website. I give permission for my child to be included in all photo/video opportunities.
I give consent for Brandon House to collect information that may be used for evaluation and/or reporting purposes.
I am aware that I am not expected to pay for my child to participate, unless otherwise stated by program requirements; but I understand I will be charged a late fee if I do not pick up my child by the time the program ends each day.
I give my consent to any exchange of information between my child’s school and Brandon House relative to grades and academic performance which may be beneficial to my child.

I/We the parent/guardian agree that we have read completely and agree to the information stated in this application for my child to participate in Brandon House programs and activities. I/We agree that the information provided is accurate and we/I agree to all the information contained in this application.

Parent/Guardian Electronic Signature (Full Name)

Signing Date