www.hollandlandoffice.com [email protected] 2015 HISTORY HEROES SUMMER PROGRAM REGISTRATION FORM Child:______________________________________________ Age:___ Entering _____ Grade Sibling (additional fees apply):__________________________ Age:___ Entering _____ Grade Parent/Caregiver:______________________________________________________________ Address:_____________________________________________________________________ City:________________________________________ State:_____ Zip:___________________ Phone: ______________________________________________________________________ Email: _______________________________________________________________________ HLOM Member □ $20.00 □ $20.00 □ $20.00 □ $20.00 □ $30.00 □ $20.00 □ $20.00 □ $20.00 Non-Member □ $25.00 □ $25.00 □ $25.00 □ $25.00 □ $40.00 □ $25.00 □ $25.00 □ $25.00 Date July 28th July 29th July 30th July 31th August 4th August 5th August 6th August 7th Description Welcome to the Holland Land Office Firefighting and Performing Arts Aviation and Fine Arts Walking Tour of Batavia & Movie Cobblestone Museum Field Trip Cooking, Weaving, Photographs Farming and Outdoor Carnival Celebration, Performance & Picnic Total Amount $________________________________________________________________ □ Check (Please make checks payable to the Holland Purchase Historical Society) □ Charge Card #:___________________________________ Exp. Date:_______________ CHILDREN’S T-SHIRTS: □ Youth Small □ Youth Medium □ Youth Large Quantity:______ □ Adult Small □ Adult Medium □ Adult Large Please complete this form and return to the address listed above. Thank you!