2010 Exploreum Camp Central Registration Form

CULTURE CAMP Members: $250 General Public: $300 Ages 9-11 years old 8:00am-3:30pm In a new, exciting collaboration, some of the top cultural, artistic, musical, theatrical, historic, and scientific institutions of Mobile join together to offer campers an experience of enrichment and fun. Campers will interact, observe, explore, and have fun at five different places. Two session are offered. 1 Camper Information Name:____________________________________________________________________________________________________ Grade (Fall2018):___________ Age______________ Male/Female Name of Parents(s)/Guardian(s): Camper Address: ______________________________________________________________________________________ Day Phone: Cell Phone: Email Address: Member of any organization involved? □ YES □ NO Additional Contact:_______________________________________________Phone:_____________________________________ 2 Choose a Session **Parents are responsible for dropping children off at the correct location each day. June 25th-June 29th August 6th-August 10th Mobile Carnival Museum Exploreum Science Center June 25th August 6th 355 Government Street 65 Government Street Bragg Mitchell Mansion Bragg Mitchell Mansion June 26th August 7th 1906 Spring Hill Avenue 1906 Spring Hill Avenue Alabama Contemporary Art Mobile Opera June 27th Center August 8th 257 Dauphin Street 301 Conti Street Joe Jefferson Players Mobile Museum of Art June 28th August 9th 11 South Carlen Street 4850 Museum Drive Exploreum Science Center GulfQuest Maritime Museum June 29th August 10th 65 Government Street 155 South Water Street 3 Meal Plan A Meal Plan option will not be available for either session of Culture Camp. Please be prepared to pack your child a lunch and snacks for each day of camp. 4 Camp Payment □ Check Enclosed (Please make check payable to the Gulf Coast Exploreum) Card Type ________________ Name on Card ______________________________________________________ Credit Card # Exp. Date Total amount to be charged to Credit Card: $ ___ Signature: _______________________ Date: 5 Permissions Form I hereby give permission for _________________________________ to attend a Summer Camp at all the locations** listed for the session chosen. I am aware that my child will participate in this day at his/her own risk and I, and my family, release the listed organizations, its directors, and its staff from any and all claims which might arise as a result of accident, injury, or illness while participating in this camp. I have indicated below any special medication, diet, or allergies of which staff should be made aware. Should the need arise, I authorize the staff at each location to obtain emergency medical assistance for my child, and I promise to indemnify and hold harmless the organizations and its staff against any loss due to expenses arising from such action. Allergies: _____________________________________________________________________________________________________ Special Diet: _________________________________________________________________________________________________ Medications: _________________________________________________________________________________________________ Do you give Exploreum Staff permission to administer the medication listed above? ________________ Parent/Guardian Signature: ________________________________________________________ Date: ___________ 6 Photo Release Form I, __________________________________, agree to give all organizations listed permission to use pictures and/or video taken of ___________________________________. These pictures can be used without limitations or restrictions as long as they are used for the purpose of promoting the organizations. Parent/Guardian Signature: ________________________________________________________ Date: _______________ *Note: If you do not agree to the photo release please do not sign this section and fill with N/A. Haley Freeman Camp Coordinator- Gulf Coast Exploreum Science Center (251) 208-6818 [email protected] Please Send Registration Form one of the following ways. Mail to: Exploreum P.O. Box 1968 Mobile, AL 36633 Fax to: (251) 208-6889 Attn: Haley Freeman Email to: [email protected] .

Load more