CAMP EARTH 2008 Registration Form
 
Camper's name Parent name
 
Camper's age Student number (office use only)
 
Address
 
City State Zip code
 
Daytime phone number Cell/home phone number
 
Emergency Contact other than listed above. Must be provided or form cannot be processed.
 
Nonmember  Member    Membership Number
 
New camper  Returning Camper
 
Phone number of emergency contact Relation to camper:
Camp Title Dates Half or Full day Fee Transportation Fee, week 9 only Office Use
           
           
           
           
           
Camp Total
Pre- and Post-Care   Pre-care
(7:30-9 a.m.)
$25 per week
 Post-care
(3-6 p.m..)
$50 per week

Please check each week that your child will be attending pre-care or post-care or both. Pre- and post-care hours are not pro-rated, and fees are non-refundable. There will be a $10 late fee for every 15 minutes past a 6 p.m. pickup.


Please initial here, indicating you have read our cancellation policy. _____

  June 9-13 June 9-13
  June 16-20 June 16-20
  June 23-27 June 23-27
  July 7-11 July 7-11
  July 14-18 July 14-18
  July 21-25 July 21-25
  July 28-Aug. 1 July 28-Aug. 1
  Aug. 4-8 Aug. 4-8
  Aug. 11-15 Aug. 11-15
     
  PRE-CARE TOTAL POST-CARE TOTAL
Payment Information Nonmember Member
_______ Camp Total

 
_______ Pre-care Total Membership Number
_______ Post-care Total  
Enclosed is a check made payable to CARNEGIE INSTITUTE
______ Total Payment     
Charge my credit card
Visa
MasterCard
American Express
 
Card number
 
Expiration date
 
Signature of cardholder

Please initial here, indicating you have read our cancellation policy. _______
EMERGENCY MEDICAL INFORMATION
In the event of an emergency, we need to have certain information easily accessible. Please complete the following and send it in with the registration form. This form must be completed in order to participate.
  
Child's name 
   
Child's age Child's birth date
  
Allergies/dietary restrictions
  
Medications* 
  
Other medical conditions we should know about 
  
Parent or guardian names 
   
Daytime phone number Cell/home phone number
   
In case of emergency, please contact Phone number
   
Child's physician Physician's phone number

* The Camp Earth staff is not permitted to dispense medication to campers. If medication must be given and you cannot be there, please make arrangements with a friend or relative to come and dispense the medication to your child. Campers are not permitted to self-medicate.
   
SIGNATURE DATE
Carnegie Museums of Pittsburgh
Program Registration Office
4400 Forbes Avenue
Pittsburgh, PA 15213-4080