Curator Club Registration Form - Messiah University

1. Child's Name Required

2. Child's Date of Birth Required

3. 2023/2024 Grade Required

4. School District/Homeschool Required

5. Street Address Required

6. Zip Required

7. City Required

8. State

9. Email Address Required

10. Name and Phone Number of Parent/Guardian Required

11. Emergency Contact (other than primary parent/guardian) Required

12. Emergency Contact Phone # Required

13. Relationship to Emergency Contact Required

14. Please check the Curator Clubs you are registering for: Required

15. How did you hear about our program? Check as many as apply

16. If Other, please describe where.