Skip to main content

How To Connect

Enroll Now! 

Brandon House Enrollment Form

Choose a BH Program

Currently, all of our 2021 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. 

Select the program the student is seeking enrollment.

 


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
Please enter the name of student who would be enrolled in Brandon House Programs.
First Name *
Middle
Last Name *
/
/
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *

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. 

 

Prefix
First Name *
Middle
Last Name *
Suffix
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Work Phone
ext Extension
Emergency Contact Information
Prefix
First Name *
Last Name *
Prefix
First Name *
Last Name *

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

Participant Health & Safety Information
/
/
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.
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?
/
/
Does your student have a physical disability?
Does your student have any chronic health problems?
Does your student attend counseling sessions?
Is your student enrolled in residential treatment?
Has your student ever been diagnosed with any of the following?
/
/
Does your student have any dietary 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?

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?

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,

  1. 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,
  2. 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,
  3.  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.
  4.  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.
  5.  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.
  6. I attest that:
First Name *
Last Name *

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

 

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.


PARENTAL RELEASE

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

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.

/
/
/
/

Our Partners