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

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

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

* 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
Parent Cell Phone
Parent Email
Student Email
Postal mail
Do not want to be notified of other gifted programs or events

* 4. Current Grade Level

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

* 5. How did you hear about the program?

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

* 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.

* 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 .)

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