Rauch Planetarium Summer Space Camp Application

Please note: Space camp registration for July 7-11 is closed. Registration for the week of July 21-25 will close after July 8.

Name of person filling out the application:
Email Address to receive confirmation:

Camper's Information (must be siblings to register on the same registration)

Check here if you will have 2 children on this application.

1st Camper's Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Gender: Male Female
Grade in Fall 2008:

2nd Camper's Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Gender: Male Female
Grade in Fall 2008:

Camp/Session Choices

Please check the session dates desired. IMPORTANT! In order to reserve a space in the camp(s) of your choice, a non-refundable registration fee is required. Registration fee amounts vary from camp to camp.

1st Camper

	Week	Name	Location	Registration Fee
	July 7-11	Space Adventure Camp	Planetarium	$250
	July 21-25	Space Adventure Camp	Planetarium	$250

2nd Camper

	Week	Name	Location	Registration Fee
	July 7-11	Space Adventure Camp	Planetarium	$250
	July 21-25	Space Adventure Camp	Planetarium	$250

Parent/Guardian Information

Parent/Guardian 1

First Name:
Last Name:
Relationship:
Mailing Address - Street: City: State: Zip:
Primary Phone: Business Name: Business Phone: Secondary Number:

Parent/Guardian 2

First Name:
Last Name:
Relationship:

Check to use above mailing address:

Mailing Address - Street: City: State: Zip:
Primary Phone: Business Name: Business Phone: Secondary Number:

Additional Authorized Pick-Up Information

In addition to the parents/guardians listed above, I authorize the following people to pick up the child/children:

Contact/Pick-Up 1

First Name:
Last Name:
Relationship:
Primary Phone: Secondary Number:

Contact/Pick-Up 2