Junior Astronaut Space Workshop

Friday, August 14 - 10 a.m. - 1p.m.

Additional registration information

Participant information

First name

Last name

Age

Street address

City State

Emergency Contact information - (Two names are requested)

Contact #1

First name

Last name

Cell phone/work phone



Relationship to participant

Contact #2

First name

Last name

Cell phone/work phone



Relationship to participant

Please note - For the safety of our participants, all children will be signed in and out by the selected parent or guardian listed above and valid photo ID will be required.

Medical Information

Are there any medical conditions that the staff should be aware of?

(Circle one) Yes No

If Yes, (provide details)

Allergies

Does the participant have any allergies?



(Circle one) Yes No

If Yes, (provide details)

Food:

Insect stings:

Other:

Medications are not allowed, Discovery Playhouse staff is not authorized to administer medications to any participant.

Release form

 (Participant's printed name)______________________________________________________  agrees to indemnify and hold harmless Southeast Missouri Children's Museum/dba Discovery Playhouse , its officers, agents and employees from and against every expense, including attorney’s fees, liability or payment by reason of any damages arising out of or in connection with the participation in the August 14th onsite event.

Participant's authorized signature

_________________________________________________

Date

_____________________________________________________________

Photos and Media Release

Signature requested at the time of participant drop off

Please bring the following

Enter items here

Communication with Workshop Staff and Discovery Playhouse staff:

Parents/Guardians are welcomed to contact staff at any time -

Discovery Playhouse main number - (573) 335-7529

Discovery Playhouse cell number - (573)979-6411

Email - info@discoveryplayhouse.org or executivedirector@discoveryplayhouse.org

We look forward to creating a fun event for your children!