EMERGENCY CONTACT INFORMATION

Childs Name: ______________________________

Childs Age: ______________

Grade: ____________

Childs Date of Birth: ________________

Siblings Names: ______________________________________

Best Way to Reach You Quickly for Same Day Updates (cancellations, etc):
(Please provide best number or email)
Text _______________

Hm Ph. _____________

Cell _______________

Wk. Ph. _____________

Email
___________________

Names of Adults Permitted to Pick Up Your Child from Program:

1. ______________________________________
2._______________________________________
3. ______________________________________
4._______________________________________
School & Doctor Information
School Name:

______________________________________________________

Address:

______________________________________________________

Phone:

______________________________________________________

School Staff Names/Email: ______________________________________________________

______________________________________________________
______________________________________________________
______________________________________________________
Doctors Name/Phone:

______________________________________________________

Other Professionals:

______________________________________________________

Parent Signature: _______________________

Parent Guide

Date: ___________________

Copyright 2015 Brain Balance Centers

LIVING ROOM GUIDELINES

Please help us make everyone feel comfortable out front in our living room. Review these
guidelines and sign below if you agree to follow these.
1. CHEMICAL FREE ZONE
a. Please do not wear perfumes, colognes, or lotions on days you come to Brain Balance
b. Please do not bring food into the living room as we want to respect people who have allergies

2. TECHNOLOGY/SCREEN FREE SPACE FOR EVERYONE (KIDS & ADULTS)

a. No screen time for any visitors in the living room (phones,ipods,ipads, laptops etc.) to support our
limited screen time recommendations during program.
b. Adults are asked to place all technology on VIBRATE and take phone calls outside or in car.
c. Wi-fi is available at Panera and other places on Riverdale Street.

3. PARENT/SELF-SERVE CAF
a. Help yourself to tea & coffee. Please let the front staff know if supplies are low.
b. Help younger kids to water
c. Bring all dirty cups up to front desk for staff to clean in back

4. CLEAN AS YOU GO/ BE A GRACIOUS GUEST

a. Whatever toys, books, or items you take out to enjoy, please have your children clean up after
themselves, or follow behind them and put things back in its place. Our staff is devoted to spending our
time supporting families while you are here, rather than policing the living room floor; and Chester, the
dog, gladly steps in as the vacuum cleaner when things are left messy.

5. CHESTER and ROLLIE - THE BRAIN BALANCE COMMUNITY DOGS

a. There are many stuffed animals in our living room, but Chester and Rollie are not one of them. Please
treat them with love and respect. They will be calm, if others are still. They will be hyper if others
are excited.
b. No picking up the dogs
c. No throwing toys in the air for them only bowling rolling things on the floor.
d. Let sleeping dogs lie if either is napping, let them enjoy their doggie dreams.

CARETAKER/PARENT: ____________________ CARETAKER/PARENT:_____________________

STUDENT:_____________________________ Date: ______________
SIBLING:______________________________ Date: ______________
SIBLING:_______________________________ Date: _________

2
Parent Guide

Copyright 2012, Brain Balance Centers