game night registration

1. Game Day Registration

Dear Gifted Student and Parents,

Thank you for your interest in our Program(s). Please take a moment to answer all 8 of the questions on this game day registration form.

I look forward to working with you,
Dr. Demetrikopoulos

Melissa K. Demetrikopoulos, Ph.D.
Director of Scientific Communications
Chair, Division of Program Development and Assessment
Energetic Einsteins
GiftedInfo@BioPhi.org

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* 1. For the following questions please provide the information requested.

Parent/Guardian:

Student names from eldest to youngest

Home phone

Address

City/Town/Zip

State

Parent Email Address

Student 1 Email Address

Student 2 Email Address:

Parent Cell Phone Number:

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* 2. Which game day(s) are you registering for? (mark all that apply)

Saturday September 29, 2012

Saturday December 1, 2012

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* 3. If you would like to hear about upcoming gifted programs or events, how do you prefer to be contacted? Please mark all that apply.

	Best Way to Reach Me	Ok way to reach me	Not an efficient way to reach me	You will never find me this way
Home Phone	Home Phone Best Way to Reach Me	Home Phone Ok way to reach me	Home Phone Not an efficient way to reach me	Home Phone You will never find me this way
Parent Cell Phone	Parent Cell Phone Best Way to Reach Me	Parent Cell Phone Ok way to reach me	Parent Cell Phone Not an efficient way to reach me	Parent Cell Phone You will never find me this way
Parent Email	Parent Email Best Way to Reach Me	Parent Email Ok way to reach me	Parent Email Not an efficient way to reach me	Parent Email You will never find me this way
Student Email	Student Email Best Way to Reach Me	Student Email Ok way to reach me	Student Email Not an efficient way to reach me	Student Email You will never find me this way
Postal mail	Postal mail Best Way to Reach Me	Postal mail Ok way to reach me	Postal mail Not an efficient way to reach me	Postal mail You will never find me this way
Do not want to be notified of other gifted programs or events	Do not want to be notified of other gifted programs or events Best Way to Reach Me	Do not want to be notified of other gifted programs or events Ok way to reach me	Do not want to be notified of other gifted programs or events Not an efficient way to reach me	Do not want to be notified of other gifted programs or events You will never find me this way

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* 4. Current Grade Level

	K	1	2	3	4	5	6	7	8	9	10	11	12
Eldest student	Eldest student K	Eldest student 1	Eldest student 2	Eldest student 3	Eldest student 4	Eldest student 5	Eldest student 6	Eldest student 7	Eldest student 8	Eldest student 9	Eldest student 10	Eldest student 11	Eldest student 12
Student 2	Student 2 K	Student 2 1	Student 2 2	Student 2 3	Student 2 4	Student 2 5	Student 2 6	Student 2 7	Student 2 8	Student 2 9	Student 2 10	Student 2 11	Student 2 12
Student 3	Student 3 K	Student 3 1	Student 3 2	Student 3 3	Student 3 4	Student 3 5	Student 3 6	Student 3 7	Student 3 8	Student 3 9	Student 3 10	Student 3 11	Student 3 12
Student 4	Student 4 K	Student 4 1	Student 4 2	Student 4 3	Student 4 4	Student 4 5	Student 4 6	Student 4 7	Student 4 8	Student 4 9	Student 4 10	Student 4 11	Student 4 12
Student 5	Student 5 K	Student 5 1	Student 5 2	Student 5 3	Student 5 4	Student 5 5	Student 5 6	Student 5 7	Student 5 8	Student 5 9	Student 5 10	Student 5 11	Student 5 12
Student 6	Student 6 K	Student 6 1	Student 6 2	Student 6 3	Student 6 4	Student 6 5	Student 6 6	Student 6 7	Student 6 8	Student 6 9	Student 6 10	Student 6 11	Student 6 12
Student 7	Student 7 K	Student 7 1	Student 7 2	Student 7 3	Student 7 4	Student 7 5	Student 7 6	Student 7 7	Student 7 8	Student 7 9	Student 7 10	Student 7 11	Student 7 12

Please note any classes taken out of their current grade level

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* 5. How did you hear about the program?

Friend

Teacher

Gifted Association

School Gifted Program

Other Gifted Program

Flyer

Other (please specify)

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* 6. Is there any other important information that we should know about your student? Please include any codes you may have been given here.

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* 7. Refer a Friend: If you know other students who may be interested in this program, please provide their contact information so that we can send them program information.

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* 8. By registering my child in this Program, I recognize that the program's activities, which may include a variety of physical activities both indoors and outdoors, could involve risk of physical injury or illness, and I assume the risks associated with these activities, knowing that despite precautions and supervision, not all risks can be prevented. Additionally, I give consent for the use of my child's photograph for educational purposes and promotion. I have/will have read the full Informed Consent Agreement and Assumption of Risk form and will provide a signed copy prior to my child's participation in the program. (A full copy can be requested from GiftedInfo@BioPhi.org .)

I agree to the above statements.

I do not agree to the above statements.