History Alive! Registration

Maximum of 10 children

Session: July 15th-19th

K-5 meets from 9-12

Cost: $175

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Email *
I would be interested in extending the camp day to 3:00pm for an additional $175?
Child's Full Name and Current Grade Level *
Who is filling out this form? *
Include full name and relationship to child
Contact Information
* phone number
* mailing address
Dietary restrictions *
Are there any allergies that I need to know about?
* If so, please describe the reaction
* Does your child have an Epi-pen?
Please list any medications that your child takes: *
In case of emergency, 911 will be called and person filling out this form will be contacted. If possible please list an additional emergency contact. In case of a non-emergency incident you will be notified ASAP. *
Please pay the $50 deposit in order to be registered for the class. This is non-refundable, but will be returned if the class is full and there are no alternative classes that work for you. *
You must make two separate payments. The $50 deposit is to hold your place in the class or on the waiting list. The remaining $125 is due at least one week before class starts. If I do not receive your full payment in time I reserve the right to give your place to the next person on the waiting list. *
Your signature and date indicate that you have read and agree to everything that is in this form. *
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