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 ____________________________________________