2017 Registration for Orpheum Fall clubs
Which club would you like to register for?
Required
Name of Child
Your answer
Parent or Guardian Name
Your answer
Contact Email Address
Your answer
Contact Phone Number
Your answer
Contact Mailing Address
Your answer
Emergency Contact Name
In the event the above parent/guardian cannot be reached at the provided contact number, please provide a second contact that we may call.
Your answer
Emergency Contact Number
Your answer
Any known allergies
if none please type "none"
Your answer
Do you have any concerns you would like us to know about in advance?
Your answer
Do you have an active membership with the Orpheum Children's Science Museum?
If so, what is your membership number?
This number can be found in the lower right-hand corner of your membership card.
Your answer
How did you hear about our clubs?
Do you need a scholarship to attend this club?
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