Community Member Registration – Brave House Community Center

Please provide the information below to register your community member with Bravehouse.

"*" indicates required fields

Member name

Date of birth

Cell phone

Email*

Address

Parent 1 name

Cell phone

Address

Parent 2 name

Cell phone

Address

Emergency contact name

Cell phone

Relationship

Primary physician's name

Cell phone

Medications

Additional information

Payments*

$100/month

$65 for one week

Checks made out to White Rabbit Foundation