AMSE Camp Registration Form

June 19 - 23rd from 8:30am - 4:00pm

As NASA prepares to return to the Moon, the American Museum of Science and Energy’s 2023 Summer Camp will explore and share what it’s like to survive in space and Martian terrain. Space campers will immerse themselves in hands-on experiments and demonstrations to replicate the astronaut's out-of-this-world experience.
Camper's Information
Camp Participant Name*

First NameLast Name
Grade entering in the fall*

5th6th7th
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Camp Participant Name

First NameLast Name
Grade entering in the fall

5th6th7th
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Primary Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Individual(s) allowed for pick up
If this box is left blank ONLY the Parent and Legal Guardian listed will be allowed to retrieve the child.
Individual(s) allowed for pick up
If this box is left blank ONLY the Parent and Legal Guardian listed will be allowed to retrieve the child.
Emergency Contact Info
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Email Confirmation
Parents Email (camper confirmation will be sent by email)*
Camper's Email
Other Information
How did you hear about Camp?
Health Information
Any activity the camper should be restricted from?
Any physical, mental or other condition that would require special attention or medication while at camp?
List any allergies (ex: bees, peanuts, dairy) or dietary needs that we should know about?
Camper Photo Release
I agree that photos of my child can be taken on used on for camp social media purposes

YesNo
Payment Information

Members: $175.00 per camper - Non-Members: $200.00 per camper

My Products

AMSE Member$175.00

Membership to the American Museum of Science and Energy

Quantity

Non-Members$200.00

Those who are not members of the American Museum of Science and Energy

Quantity

Total $0.00

Credit Card

- Be certain to enter your email address correctly on the registration form to receive confirmation.
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. The camp carries secondary insurance. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites.
Electronic signature, please initials*
Should be Empty:

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June 19 - 23rd from 8:30am - 4:00pm

Camper's Information

Parent or Legal Guardian Information

Emergency Contact Info

Email Confirmation

Other Information

Health Information

Camper Photo Release

Payment Information

Credit Card