Historical Museum of Southern Florida Graphic
 
Winter Break Camp Registration Form 2007-2008

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 Frank Schena at 305-375-1629 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  
Dates Information
  HMSF members Non-members
Wonders of Wintertime
Dec. 26-28, 2007 		$90 $105
South of the Border
Jan. 2-4, 2008		 $90 $105
Fee includes snack. Children must bring their own lunch. To become a Historical Museum member, call 305.375.1492
I wish to make a contribution to the museum's Tropical Explorers Camp Scholarship Fund
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:
Mail to:
Historical Museum of Southern Florida
Attn: Education Department
101 West Flagler Street
Miami, Florida 33130
Fax to: 305.372.6315
For additional registrations, please photocopy this form and fill out for each additionregistration.
If mail or fax in your registrations then the confirmation letters will be mailed upon receipt of your registration form and full payment.