Summer with the Past

Children will need to bring their own snack, drink, and lunch. Please have children arrive on time to begin the day’s activities and please pick them up promptly at the end of the day’s program. We look forward to meeting your child and sharing a fun week of history and activities. Feel free to contact us with any questions.

Contact Information

Student Name (First, Last)

Please enter the name of the student

Parent/Guardian Name

First Name

Last Name

Parent/Guardian 2 Name

First Name

Last Name

Verify Email

Parent/Guardian Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Student age

Preferred phone number

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Insurance information *

Is the participant covered by family medical and hospital insurance?

Yes

Permission to share image

On behalf of the participating child(ren), we hereby give permission for the participant(s) to be photographed or videotaped for educational or promotional purposes during the program.

Yes

Insurance Provider and Policy Number

Please enter name of Insurance Provider and Policy Number

Name of Physician and Physician's Phone Number

Please enter name and contact information for participant's physician.

Allergy History

Is the child allergic to any food, medication, or other substance?

Yes

Allergy History

If "yes" please list all allergies and describe child's reaction. Please include any relevant additional information.

Allergy History

Has the child ever had an unusual reaction to an insect bite or bee sting? If "yes" please explain below.

Yes

Please describe any unusual reactions to insect bites or bee stings.

Dietary Restrictions

Although all children will be provided food for snack and lunch by their parent/guardian, please list any food allergies or restrictions we should be aware of.

Session selection

Please choose which session your child would like to attend

Week One: June 24 – 28, 9:00 am – 1:00 pm, Ages 7 -11, $100 ($90 with member discount)

Week Two: July 22-26, 9:00 am- 1:00 pm, Ages 12 – 15, $110 ($100 with member discount)

Week Three: August 5-9, 9:00 am to 3:00 pm, Ages 7 – 11, $150 ($140 with member discount)

Financial Assistance requested?

Limited financial assistance is available. Please check here if you are requesting financial assistance and please contact ltm@roadrunner.com. Requests and details relating to financial aid will remain confidential.

Yes

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