Science Station Summer Programs Registration Form

(Please print clearly)

Child’s Name:
Age:
Grade completed in May 2001:
Member
Non-Member
Parent/Guardian Name:
Address:
City:
State:
Zip:
Daytime phone:
Cell phone:
Email:
Emergency Contact:
Phone:

Enroll my child in the following programs:
Class Title	Dates	Cost

Noontime:	Dates:

____ Include a one-year Family membership for $70.

Total Amount Enclosed: ____________

Please Fill out and return with Registration form and payment.

I, the undersigned, as the parent/guardian of ____________________, give permission for my child(ren) to participate in the Science Station Summer Program. My student has permission to leave the museum for field trips, appear in pictures for publicity purposes, receive emergency medical care if necessary, and agree to not attend workshop or camp if exposed to any contagious disease. I accept full responsibility for my child(ren)’s medical bills and all other associated expenses as a result of injuries or illnesses sustained while in attendance. I understand that Science Station is not responsible for lost or stolen items and will not be responsible for refunds for any given classes missed by the student. _____My child(ren) is allowed to leave Science Station premises at the end of the workshop/camp day. _____My child(ren) should stay on premises until a specified adult picks him/her up.

My child(ren) requires the following medicine at a certain time each day.
Medication Name	Dosage	Time of Day

My child(ren) is allergic to:
Family Doctor Name
Phone Number
I have read the summer program information and agree to comply with all procedures and requirements.
Signature	Date

Fax this form to: Science Station, (319) 366-4590 or send to:

Summer Programs
Science Station
427 First Street SE
Cedar Rapids, Iowa 52401

Copyright © 2001 by Science Station & McLeod / Busse IMAX® Dome Theatre and Procend Inc. All rights reserved.
Designed and developed by Procend Inc.