Nuero Glow Kids
Every Wednesday, 1pm-3:30pm, Price: $25 per person or $50 for drop offs
What Wednesday date for Nuero Glow Kids are you signing up for?
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Month
-
Day
Year
Date
Is an adult staying with the child(ren)?
*
Yes
No
Are you a KiDiMu member?
*
Yes
No
How many children are being registered?
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1
2
3
4
Adult's name
*
First Name
Last Name
Adult's relationship to child(ren)
*
Mother
Father
Other
Adult's phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Adult's email
*
example@example.com
Adult's postal code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child 1's name
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First Name
Last Name
Child 1's age
*
2 1/2
3
4
5
6
7
8
9
10
11
12
13
14
Other
Child 1's grade
*
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Other
Child 1's allergies (If any)
Child 1's disabilities (if any)
Child 2's name
*
First Name
Last Name
Child 2's age
*
2 1/2
3
4
5
6
7
8
9
10
11
Other
Child 2's grade
*
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
Other
Child 2's allergies (If any)
Child 2's disabilities (if any)
Child 3's name
*
First Name
Last Name
Child 3's age
*
2 1/2
3
4
5
6
7
8
9
10
11
Other
Child 3's grade
*
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
Other
Child 3's allergies (If any)
Child 3's disabilities (if any)
Child 4's name
*
First Name
Last Name
Child 4's age
*
2 1/2
3
4
5
6
7
8
9
10
11
Other
Child 4's grade
*
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
Other
Child 4's allergies (If any)
Child 4's disabilities (if any)
Additional information (if any)
I grant permission to KiDiMu to use photographs or videos of myself and my child taken during museum visits or programs for educational or promotional purposes.
*
Yes
No
I am agreeing to KiDiMu's Health, Safety Policy, & Waiver. (Questions about policies & waivers can be directed to learnmore@kidimu.org)
*
Yes
Signature
*
Date
*
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Month
-
Day
Year
Date
Payment
*
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Attendance (Supervised)
$25.00
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Attendance (Staff Supervised)
$50.00
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
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