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User Profile Information

Username*

Enter a username for your login ID (we recommend using your email address). Once created you cannot change your username.

Password*

Enter Password Confirm Password

Email*

Enter Email Confirm Email

Family Contact Information

Parent/Guardian (1)*

First Last

Parent/Guardian 1 Relationship*

Parent/Guardian (2)

First Last

Parent/Guardian 2 Relationship

Primary Phone Number - We call this number first for communication or emergencies*

Phone - Parent/Guardian (2)

Alternate Phone - Parent/Guardian (1)

Alternate Phone - Parent/Guardian (2)

Alternate Emergency Contact (Not Parent / Guardian)*

Please provide a NAME and PHONE NUMBER. We require contact information for at least two adults for the safety of your child.

Alternate Emergency Phone*

Relationship for Alternate Emergency Contact*

Relationship for Emergency Contact*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Complete information for each child

Child 1*

First Last

Gender 1*

Male
Female
Prefer to not identify

Birthday 1*

MM

DD

YYYY

Grade in School 1*

2022-23 school year

Does Child 1 have any allergies or important medical information?*

Yes
No

Allergies/Medical Info 1*

Add second child?*

Yes
No

Child 2

First Last

Gender 2*

Male
Female
Prefer to not identify

Birthday 2*

MM

DD

YYYY

Grade in School 2*

2022-23 school year

Grade in School 2 OLD

Does Child 2 have any allergies or important medical information?*

Yes
No

Allergies/Medical Info 2*

Add third child?*

Yes
No

Child 3

First Last

Gender 3*

Male
Female
Prefer to not identify

Birthday 3*

MM

DD

YYYY

Grade in School 3*

2022-23 school year

Grade in School 3 OLD*

Does Child 3 have any allergies or important medical information?*

Yes
No

Allergies/Medical Info 3*

Add fourth child?*

Yes
No

Child 4

First Last

Gender 4*

Male
Female
Prefer to not identify

Birthday 4*

MM

DD

YYYY

Grade in School 4*

2022-23 school year

Grade in School 4 OLD*

Does Child 4 have any allergies or important medical information?*

Yes
No

Allergies/Medical Info 4*

Is there anything additional you would like us to know about your child(ren) to ensure a successful experience at Noggin Builders?

Emergency Medical Authorization and Acceptance of Noggin Builder Policies

Emergency Medical Authorization and Acceptance of Noggin Builder policies*

I have read and agree to the Noggin Builders policies defined below

The health information provided is correct and complete to the best of my knowledge and belief. The child herein described has parental/legal guardian permission to engage in all program activities. I hereby give permission to Noggin Builders, LLC to provide emergency care and seek emergency medical, surgical, or dental treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for payment, treatment, or insurance purposes. In the event of an emergency, I give permission to Noggin Builders, LLC to arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician/health care provider selected by Noggin Builders, LLC to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied, if needed. I understand that the child(ren) named herein will be participating in programs and activities at Noggin Builders, LLC. I acknowledge that such programs and activities involve inherent risks. I release and forever discharge and indemnify Noggin Builders, LLC and its employees, members, officers, agents, and representatives from any and all damages and causes of action including attorney's fees as a result of my child(ren)’s participation in any activities at or associated with Noggin Builders, LLC. I give my permission to Noggin Builders, LLC to use any video or photograph, either online or in print, or any video taken at the event my child is attending for the purpose of marketing or promoting Noggin Builders, LLC and its programs.

By typing my name below, I acknowledge that I accept the policies stated above.*

Date Accepted*

MM

DD

YYYY

How did you hear about Noggin Builders?*

If "Other", please list*

Referred to Noggin Builders by*

We like to acknowledge our customers that refer new families to Noggin Builders. Please provide the name of the person who referred you to Noggin Builders. Thank you!

Please type the content below:

User Profile Information

Family Contact Information

Complete information for each child

Emergency Medical Authorization and Acceptance of Noggin Builder Policies

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