2012 Half-Pint Program Registration Form

Fill Circle(s) Below

Camp

Price

Notes: 

OOO

OOO

OOO

OOO

OOO

Tree Homes

3,2, 1 Blast Off!

Engineers in Training

Games Galore

Wild, Wet Science

1/11/12

2/1/12

3/7/12

5/2/12

5/16/12

2 - 5

2 - 5

2 - 5

2 - 5 

2 - 5

$8/Member;

$12/Non-Member.

Additional Children or Adults: $4/Member, $6/Non-Member

 All programs are 1:00 - 2:30 pm. Check-in from 12:30 - 1:00 pm.

_____________________________   _________________

Name                                                Birthdate (child #1)

_____________________________   __________________

Name                                                Birthdate (child #2)

________________________________________

Name (parent/guardian)

________________________________________

Mailing Address

________________________________________

City, State, Zip

________________________________________

Phone

________________________________________

E-mail

Subtotal:           ________

Member #:        ________

Total:                ________

Contact Jim Hodgin at 260-424-2400 ext 451 for more information.

Faxes:

260-422-2899

O Check

O Visa

O MasterCard

O Discover

Name on Card: _____________________________________

Billing Address for Card: _____________________________

__________________________________________________

Credit Card #: ______________________Exp: Date:_______

Signature:_________________________ Security code: ______

Send to:

Science Central

1950 N. Clinton

Fort Wayne, IN 46805

www.sciencecentral.org