Historical Museum of Southern Florida Graphic
 
Spring Break Camp Registration Form 2008

Pleace complete the form below and click the Submit button. If you are registering more than one child you will need to register each child separately.

If you have any questions please call 305-375-1492 or e-mail education@hmsf.org
Student's Information
First Name
Last Name
Gender Male Female
Date of Birth
Age
Home Phone Ex. 305-555-1234
Home Address 1
Home Address 2
City State Zip
Parent/Guardian’s Information
First Name
Last Name
Work Phone Ex. 305-555-1234
Cell Phone Ex. 305-555-1234
Home Phone Ex. 305-555-1234
Email
Same as Student Information above (This is for billing purposes.)
Address 1
Address 2
City State Zip
Country
Medical Information
List Any Medications
List Any Allergies
Special Needs
Emergency Contact
Phone
Physician’s Name
Phone
Please List Any Other Person(s) Authorized to Pick up Your Child (Separate names by commas)
Dates Information
Only One Everglades
Monday, March 31 - Friday, April 4
  HMSF members Non-members
Full Payment $120 $125
For alternative payment options, please contact Frank Schena at 305.375.1629
Fee includes snack. Children must bring their own lunch.
I will not be registering a child but wish to make a contribution to the Historical Museum in the amount of $

If you prefer to mail this form to us please complete the registration form (please print) and send with full payment to:
Education Department,
Historical Museum of Southern Florida
101C West Flagler St.
Miami, FL 33130

Confirmation letters will be mailed upon receipt of your registration form and full payment.

For additional registrations, please photocopy this form. For more information, call 305-375-1492.