Page 1 of 2 REGISTRATION / RELEASE: PIONEERPALOOZA 2015 Hiwan Homestead Museum, Evergreen ONE FORM PER CHILD, PLEASE COMPLETE BOTH PAGES ___________________________________________________ __________________________ Child’s Name Child’s Age ________________________________________________________________________ Address City State ______________________________________________________________________________ Parent / Guardian Name Home Phone Work Phone Cell Phone ____________________________________________________ ________________________ Parent’s Email ____________________________________________________ ________________________ Emergency Contact Relationship Home Phone Cell Phone ______________________________________________________________________________ Family Physician Phone Child’s Allergies Dates: June Monday 22nd – Friday 26th (One Week Only!) Time: 9:30 – 3:30 PM (campers get free supervised lunch) Fee: $125 per week Junior Pioneers (ages 7 – 9) My child is __ years old and will remain on Hiwan grounds. Pioneers (ages 10-12) My child is __ years old and I authorize Hiwan staff to transport my child to Open Space parks in the afternoons. OR: My child is __ years old and I do not authorize Hiwan staff to transport my child to Open Space parks in the afternoons (Child will stay on Hiwan grounds in the afternoons). Space is limited. You must pre-register your child to participate in this program. Page 2 of 2 Make checks payable to: Jefferson County Historical Society (The $125 fee must accompany registration) Registration & the signed release MUST be brought before or on the first day of camp for admission. NO refunds will be made after the registration is confirmed. A child who is a discipline problem will be excused from the program without a refund. Release: I waive any rights I may otherwise have against the Jefferson County Historical Society, Inc. (JCHS) arising from the participation of my child:_________________________ in the programs at the Hiwan Homestead Museum, and release Jefferson County Historical Society and its representatives from any liability. The Jefferson County Historical Society will take every precaution for the safety of your child. I give full permission for my child to attend Pioneerpalooza sponsored by the Jefferson County Historical Society and to particulate in all of its program activities. Education staff may take photographs during the course of some Pioneerpalooza activities. May we use photographs of your child for publicity purposes? ____ YES ____ NO I, ___________________ (Parent / Guardian) authorize the following individuals to pick up my child: _____________________________ _____________________________ _____________________________ _____________________________ ____________________________________________________________________________ Signature (Parent / Guardian) Printed Name Phone Date For more information: Andy Spencer, Education Coordinator 720-497-7650 [email protected] Pioneerpalooza Hiwan Homestead Museum, 4208 S. Timbervale Dr., Evergreen, CO 80439.