Summer Camp Registration

Name of person filling out application

Email Address (for email confirmation)

Are you already a Gheens Science Hall & Rauch Planetarium Member? (Please note that you must have an active membership at the time of the summer camp to be eligible for the member discount.)
Yes No

Sign up for a membership if you wish to become a member and receive discounts on workshops and camps as well as free admission to regular planetarium shows.

Camp/Session Choices

Child 1

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Choose a camp session

Child Information

Parent/Guardian Information

Parent/Guardian 1 Information

First Name

Last Name

Primary Phone Number [###-###-####]

Secondary Phone Number [optional: ###-###-####]

Street Address 1

Street Address 2 [optional]

City

State [All Caps]

Zip Code

Parent/Guardian 2 Information [optional]

First Name

Last Name

Primary Phone Number [###-###-####]

Secondary Phone Number [###-###-####]

Street Address 1

Street Address 2 [optional]

City

State [All Caps]

Zip Code

Additional Authorized Pick-Up Information [optional]

Contact/Pick-Up 1 Information

First Name

Last Name

Relationship

Primary Phone Number [###-###-####]

Secondary Phone Number [optional: ###-###-####]

Contact/Pick-Up 2 Information

First Name

Last Name

Relationship

Primary Phone Number [###-###-####]

Secondary Phone Number [optional: ###-###-####]

Physician/Insurance Information

Name of Family Physician

Phone Number [###-###-####]

Insurance Carrier

Policy Number

Child 1 Medical Information [optional]

List any physical conditions, previous injuries, or medical issues that we should know about.

List any allergies your child may have.

List any medications your child is currently taking.