Historic Fort Steuben
PO Box 1787 120 South Third Street
Steubenville OH 43952
740-283-1787
SUMMER 2009
YOUTH EDUCATIONAL PROGRAM
REGISTRATION FORM
Please fill out and sign the following form and return it with your registration fee by June 12th for Session 1,
by July 9th for Session 2.
NAME OF STUDENT ________________________________________________________
GRADE COMPLETED_______ AGE ______
NAME OF PARENT _________________________________________________________
ADDRESS ________________________________________________________________
_______________________________________________________________
PROGRAM SESSION 1_______ PROGRAM SESSION 2______
PHONE (WHERE PARENT CAN BE REACHED DURING PROGRAM SESSION)
____________________________________________________
MEDICAL ALERTS
DOES YOUR CHILD HAVE ALLERGIES OR MEDICAL CONDITIONS THAT WE MUST KNOW ABOUT?
PLEASE LIST (E.G. BEES, WASPS, ASTHMA, FOODS, OR WOOL)
_________________________________________________________________________
_________________________________________________________________________
MEDICAL RELEASE
IN CASE OF EMERGENCY, OLD FORT STEUBEN HAS MY CONSENT TO CONTACT (FAMILY DOCTOR:
NAME & PHONE)
__________________________________________________________________________
IN CASE OF EMERGENCY, OLD FORT STEUBEN HAS MY CONSENT TO TAKE MY CHILD TO THE
NEAREST HOSPITAL OR MEDICAL FACILITY FOR NECESSARY TREATMENT.
HOLD HARMLESS
ALTHOUGH OLD FORT STEUBEN MAKES EVERY ATTEMPT TO MAINTAIN SAFE AND SECURE
CONDITIONS, NEITHER THE FORT NOR ANY OF ITS STAFF, VOLUNTEERS OR BOARD MEMBERS WILL
BE RESPONSIBLE FOR ANY LOSS OR DAMAGE INCURRED DURING THE SUMMER EDUCATIONAL
PROGRAM. IT IS RECOMMENDED THAT ALL PARTICIPANTS HAVE INSURANCE COVERAGE.
PARENT SIGNATURE ____________________________ DATE ___________