Child's Name:
Age:		Grade (entering):
Parent or Guardian's Name:		Birthdate:			/ /
Street Address:
City:			State:		Zip:
Home Telephone:
Cell or Work Telephone:
Email Address:	No Email Address
Emergency Contact:			Phone:
Medical Information / Allergies / Adaptations:
Family Doctor:			Phone:
Preferred Hospital:	Holy Spirit Harrisburg
Curator Club Fall 2009 Schedule - Please check the activities your child will be attending:
September 12th The Dirt on Dirt!   October 31st Creepy Crawlies, Gooey Gross-outs and More!   September 26th Living on the Edge November 7th Monkey Business! October 10th Can You Dig It? November 21st YOU be the Judge! Registration is required only once per session. Any changes in registration for an activity may be submitted through email at curatorsclub@messiah.edu
Photo Permission I give permission for my child's photograph to be taken during Curator Club activities. I understand the photographs may be used in the Oakes Museum newsletter or promotional material (which may include our web site) or for staff professional portfolios. Yes No
Parent Signature:			Date:	/ /
Permission to Pick Up Your Child At the end of Curator's Club we will only release your child to those who may pick up your child. I authorize the following individuals to pick up my child from the Oakes Museum Curator's Club.
Name:			Phone:
Parent Signature:			Date:	/ /
If you need to make arrangements for another person to pick up your child during Curator Club sessions, please provide us with a written and signed note of permission.