* 1. Child's name:

* 2. Date of Birth:

Date / Time
/
/

* 3. Parent/Guardian Contact Information:

* 4. Please note the top three camp choices for your child. Scholarships are given based on availability of the camp at the time the scholarship is approved. Camp preferences are not guaranteed.

* 6. Number of adults living in the household?

* 7. Number of children living in the household?

By submitting this form, I understand that if the child indicated above receives a summer camp scholarship, I am responsible for transportation to and from camp. Extended care during camp season is not available. I understand that the scholarship is not transferrable. The Greensboro Children's Museum will contact the parent or guardian of the scholarship recipient no later than two weeks prior to camp commencing. At that time, a $10.00 nonrefundable registration fee must be submitted, along with a Medical and Emergency Contact Form. Please direct all inquires to Heather Oakley, Camp Coordinator, at 336.574.2898 ext 302.

T