Petrolia Train Your Brain Registration Train Your Brain | Petrolia Parent Name(Required) First Last Email(Required) Enter Email Confirm Email Main Phone Number:(Required)Alternate Phone Number:Home Community:(Required)PetroliaSarniaMooretownCamlachieOtherPlease provide names and grades of all children you are registering.NOTE: This program is only for kids currently enrolled in grade 3 or 4First Child's Name:(Required) First Last Please select grade:(Required)Grade 3Grade 4Second Child's Name: First Last Please select grade:Grade 3Grade 4Would you like to receive email updates on upcoming courses?(Required) Yes No How did you learn about the Literacy Lambton Programs or how did you find out about this course? Please check all that apply.(Required) Social Media Newspaper Word of Mouth Poster/Community Board Program and Activity Guide Coffee News Email Radio Agency Referral Other Agency Referral or Other? Please share where: Are there any learning challenges you want us to be aware of?(Required) No Yes If yes, what is your challenge? Voluntary Disclosure: Are there any pre-existing medical issues we need to be made aware of?(Required) No Yes Pre-Existing Medical Condition/Medication: Emergency Contact #1 - Name, Relationship and Phone Number(s) Emergency Contact #2 - Name, Relationship and Phone Number(s) Throughout the year we like to promote our programs to the media, on our website, social media sites, newsletters and bulletin boards. In order to video tape, photograph or interview our participants we need your permission to publish to these public sources. Under the Freedom of Information and Protection of Privacy Act (FOIP) Literacy Lambton requires the consent to use your information outlined as above.Please complete the information below with a check mark to indicate your choice:(Required) Yes, I give my consent for the publication of my name, image or comments to be used for the purpose described above. No, I do not give my consent for the publication of my name, image or comments to be used for the purpose described above. Consent to Release Information(Required)In order to facilitate our programs we are required to share information with our instructors. I give permission for Literacy Lambton to share the personal information that I have provided, along with information about my learning, with my instructor. Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.