Monday, December 6, 2013, 9:00 a.m. – 4:00 p.m.*
First Name: Last Name:
School: Grade as of Fall 2013: Age:
Home Phone: Work Phone: Cell Phone:
Relationship to Student:
Adult (other than those above) authorized to pick up child:
Emergency Contact (other than those above):
Medical Information (allergies, medications, diet restrictions): This information is confidential and will not be shared with anyone other than your child's camp instructor.
Learning or behavior needs (learning disabilities, behavior issues that may affect group learning): This information is critical in ensuring the very best experience for your child.
Payment Due You may pay with a check by mail to the address listed below or pay by card in person or over the phone.
$50 per child $40 per child for MNCH members (members receive discounts on programs throughout the year including summer camps, family days and no-school day programs, as well as free admission to exhibits all year).
*After care is available until 5:15 p.m. for an additional $10
Your registration is not finished until you complete the steps below:
In addition to filling out and submitting the form above, you will need to download, sign, and submit a Release of Liability and Emergency Medical Care and a Media Authorization.
You may either mail or drop off the permission form with your payment to 1680 East 15th Ave., Eugene, OR 97403-1224.
Questions or payment by phone at 541-346-3116 or in person, 9 a.m.-5 p.m. Monday through Friday
University of Oregon Museum of Natural and Cultural History 1680 E. 15th Ave.Eugene, OR firstname.lastname@example.org