Program Release & Payment Form
If you have more than four (4) children, please contact us at 618-529-5431. Membership will be confirmed upon arrival for submissions with a Membership Rate selected.
Child's Name
*
First Name
Last Name
Child's Birth Date
*
Additional Children
Second Child's Name
First Name
Last Name
Second Child's Birth Date
Third Child's Name
First Name
Last Name
Third Child's Birth Date
Fourth Child's Name
First Name
Last Name
Fourth Child's Birth Date
Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Alternate Guardian
First Name
Last Name
Phone Number
Please enter a valid phone number.
Emergency Contacts (in case we cannot reach guardians)
*
Please list all people allowed to pick up your child
*
Allergies/Aversions Please list all allergies, sensory issues, phobias (fear of storms, stickers, animals, etc.) or other concerns. Our programs may use food, latex, milk, soy , red dye, or other food allergens and there may be loud noises, animals, eruptions, or other startling events.
Allergens
Sensory or Other Aversions
Photo Release Sometimes photographs or video arein the Science Center for use in local news or our website, Facebook, andnewsletter. We also take photographs of some programs to email back toparents.
*
I give permission for my child’s photo and firstname to be used
I give permission for my child’s photo (no name)to be used
I do not want my child’s photo used
Other relevant information
Date
*
Guardian Signature
*
*
Which GUNO are you signing up for?
*
September 16th: Celebrating National Play Doh Day
October 21st: National Reptile Day
November 18th: Looking to the Stars
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GUNO
$
25.00
Number of Children
1
2
3
4
5
6
7
8
9
10
GUNO (Member Rate)
$
20.00
Number of Children
1
2
3
4
5
6
7
8
9
10
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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