Registration

2013 Summer Camp Registration

* Denotes a mandatory field

Membership Number

Member's Name

(if other than parent)

Parent's Name *

Child's Name *

Gender *

Male
Female

(Pick one)

Name to use on name tag

Date of Birth *

MM/DD/YYYY

Entering Grade *

(select one)

Program Name and Date *

Check the days you need AfterCare.

Monday
Tuesday
Wednesday
Thursday
Friday

Aftercare is available until 5 p.m. for an additional $15 per day or $60 if you register for the entire week.

T-shirt Size *

(Each child receives one T-shirt)

Address *

Address 2

City *

State *

Zip *

Home Phone *

Work Phone

E-mail *

Agree to photo release below

I hereby grant Fernbank Museum of Natural History the right and permission to publish my child’s photographic image for the purpose of marketing literature and publication to their website. In giving my consent, I hereby release and hold harmless Fernbank Museum of Natural History, their employees, agents and designees from any and all responsibility or liability. I understand that I will receive no compensation should any photographs of my child be used.