Fill out this form and click submit. Then, click on PayPal to pay by credit card. Pay by check by sending check to Brain Brigade, PO Box 639, Estero, FL, 33928. Write the child's name on the MEMO line of check so we can match with the registration form.

Child's First Name:

Child's Last Name:

Date of Birth:

Grade Entering for 2010-2011 School Year:

 Child's Gender:

Female

Male                            

July 5-9, 2010 Girls In Science 9am-5pm

Session 1

July 12-16, 2010 Experiment Extravaganza

Session 2

July 19-23, 2010 Robotics for Beginners 

Session 3

July 26-30, 2010 Robotics-Intermediate

Session 4

July 26-30, 2010 Book Club and Writers Rock

Session 5

Parent's Last Name:

Parent's First Name:

Parent's Address (Street Number and Name):

Parent's City, State, Zip Code:

Phone Number:

Phone Number (Cell):

Phone Number (Cell #2):

Email Address:

Email address (2):

Additional Contact Information:

Additional Contact Person's Name/Phone Number:

Additional Contact Person's Relationship to Child:

Pertinent Medical Information-Food Allergies(allergies/disabilities, etc):