LIMITED SEATS

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LIMITED SEATS ☆

SUMMER PROGRAM REGISTRATION

Our summer brain training program is designed to help kids and adults improve their cognitive functions and mental wellbeing. We offer neurofeedback therapy and brain training activities to enhance attention, focus, memory, emotion regulation, etc.

PROGRAM DATES: The program will start on July 9, 2024.

LOCATION: We have locations in the Bronx and Hoosick Falls.

REGISTRATION: Please complete the registration form below by May 31, 2024. This is not a guarantee of your/your child’s spot in our program. We will reach out to you via email for more information to determine if our program is the right fit for you/your child.

Name of Participant

First Name

Last Name

Participant's Sex/Gender

Male

Female

Non-Binary

Other

Participant's Date of Birth

MM

DD

YYYY

Participant's / Parent's Phone Number

Please include a parent's phone number if the participant is a child

(###)

###

####

Participant's / Parent's Email Address

Please include a parent's email if the participant is a child

Parent/Guardian's Name

Please complete this if the participant is a child

First Name

Last Name

What grade will your child be in during the upcoming school year (September 2024)?

Please complete this if the participant is a child

Which location are you interested in attending?

The Bronx

Yonkers

Hoosick Falls

Medical Information

Optional space for you to share any information you would like us to know about the participant. Ex: mental health struggles, diagnoses, disabilities, etc.