Online Registration - Winter 2015

Please fill out the following information - you will make your purchase on the next page. * Denotes a required field.

Enrollment Information:

Which class(es) are you signing up for? *
Please read the class descriptions on this website for each class you select to ensure you know their times and locations.

Register for one class, and get 10% off any additional classes!

Adults:



Kids:




Teens:





Student Information:
Student Status: *  
First Name: * Last Name: *
Student's Date of Birth: *   
Parent/Legal Guardian Name:
Home Telephone: *
Parent's Mobile Phone:
At which number can you be reached between 4pm and 6pm? *
Street Address: *   
City: *       Zipcode: *
Parent/Student Email: *
Primary Language Spoken: *
School Attending:
School Type: Grade Level:  
School Start Date:   
Preferred Contact Method: *
Emergency Contact Name: *
Emergency Contact Phone: *
Relationship to Emergency Contact: *
Does the student have any special medical conditions? If so, please list them:
I give permission for my child to walk home alone at dismissal:
My child may NOT be picked up by the following person(s):
How did you find out about us?

 

Demographic Information: Note: This information is very important. It will allow us to continue providing quality, affordable services in your community. BRAC respects an individual's right to keep certain personal information private, and any information provided here will be recorded anonymously and used solely for the important purposes of improving BRAC's program offerings and fundraising. BRAC will not sell, trade, or transfer any individual's personal information to any third party or entity. If you have any questions or concerns regarding the information you provide, please contact us.
Gender:
Ethnicity:
Race:
(check all that apply)

Other Characteristics:
check all that apply)


Employment Status:
Student Status:
Highest Education Level:

What is your neighborhood's Council District Number OR who is your neighborhood's Council Member?

If you do not know this information, please
click here and simply put in your address to
find out.


Household/Parent Information:
Household Type:
Number in Household:
Housing:
Primary Source of Income:
If Applying for a Scholarship, yearly gross income: $
Receiving Food Stamps?

BRAC Attendance Agreement: *

Photo/Video/Interview Consent: *

Certification Statement *

 

Please be sure to read our policies and procedures. Click here to view.

Registration is not complete until payment is made via PayPal.