Yes! I want to register for
Junior Space Week
June 23- 27, 2025
Student name
*
Student address
*
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State
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Alaska
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Connecticut
Delaware
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AA
AE
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Parent/Guardian name
*
Parent/Guardian address
*
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State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
AA
AE
AP
Parent/Guardian email
*
Parent/Guardian phone number
*
Parent/Guardian phone number (additonal)
Question for student: Why are you signing up for Junior Space Week? What are you looking forward to the most, or what are you hoping to learn?
*
Student is going into what grade?
*
3rd grade
4th grade
Student gender
*
Male
Female
Student t-shirt size
*
(Choose One)
child small
child medium
child large
adult small
adult medium
adult large
adult x-large
Student name on t-shirt
*
Does the student have any allergies or foods they cannot eat?
*
Yes
No
If yes, please explain
Does the student have any special needs, or are there special circumstances we should know about? (Unfortunately the museum is on the 2nd floor and is not easily handicap accessible).
*
Yes
No
If yes, please explain
Friday at the end of the camp we will be holding an ice cream sundae social to celebrate the week. All students and their families are invited to attend. Including your Junior Space Week student, how many people will attend?
*
Emergency contact name
*
Emergency contact phone number
*
How is the emergency contact connected to your child?
*
Terms
*
I certify that my child has my permission to participate in Junior Space Week. I hereby release the Deke Slayton Memorial Space & Bicycle Museum and their employees from any liability, claims, lawsuits, etc. from any injury or illness that may result from participation in Junior Space Week. I certify that my child is in good physical health and can participate in all camp activities. I further certify that the above camper has medical insurance in case of an emergency. Junior Space Week and the Deke Slayton Memorial Space & Bicycle Museum, the directors, and any staff shall not be held responsible for personal injury of any student or loss of individual property during the camp. I grant permission for the camp directors to act on my behalf in case of medical emergency. I understand that I am responsible for all medical expenses.
I have read and agree to the terms above.
Terms
*
I release the Deke Slayton Memorial Space & Bicycle Museum and Junior Space Week from any liability, claims, lawsuits, etc. from any injury or illness my child may suffer during their participation in any event organized by the Deke Slayton Memorial Space & Bicycle Museum.
I have read and agree to the terms above.
Terms
*
I grant the Deke Slayton Memorial Space & Bicycle Museum the right to take photographs of me, my child, and my family in connection with the above identified event. I authorize the Deke Slayton Memorial Space & Bicycle Museum, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that the Deke Slayton Memorial Space & Bicycle Museum may use such photographs of me, my child, and my family with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
I have read and agree to the terms above.
Terms
*
I have read and fully understand the general terms and conditions as outlined in this registration form and I give my child permission to participate in Junior Space Week.
I have read and agree to the terms above.
Date
*
Any other information you would like us to know.
Registration Options
*
Early bird price ($225.00) [Sold Out]
only available through April 14
Full price ($255.00) [11 remaining]
Billing Information
Email
*
Name
*
Credit Card
*
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Address
*
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State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Missouri
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Nevada
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Oregon
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AE
AP
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