Old Tyme Country School Registration Form |
| PLEASE PRINT: Student Name______________________________________ Age__________ Grade Just Completed______ Name of Parent(s)/Gardian___________________________________________________________________ Mailing Address___________________________________________________________________________ City ________________________________________ State _____________ Zip_______________________ Phone Numbers: Day _____________________ Cell ___________________ Alternate ___________________ Session (circle one) I July 25-29, 2011, II Aug. 1-5, 2011, III Aug. 8-12, 2011 Have You Attended Old Tyme Country School in prior year(s) (circle one) NO YES If Yes, please list grade(s) ______________________________________________________________________ Health Information: Any health conditions we need to know about? (Allergies, daily medication, etc.) __________________________________________________________________________________________ Fee Enclosed: $___________ ($40 per student Kanabec History Center Membera or $50 non-members) Make Checks payable to KHC. Submit this form and fee to: Kanabec HIstory Center PO Box 113 Mora, MN 55051 OR Drop off at the Kanabec History Center 805 West Forest Avenue in Mora 320-679-1665
Date: ________________________ Signature ____________________________________________ |