2019 Registration for Orpheum Fall Clubs
Please remember this form does not complete registration. You will need to place your payment once this form has been completed in order to finalize your registrations.
Email address *
Which club would you like to register for? *
Required
Name of Child *
Your answer
Parent or Guardian Name *
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
I agree to allow the Children's Science Museum to photograph my child. *
Please be sure to review our photo and video disclaimer found on our website for details.
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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