Student InformationStudent Name* First Last Student GradeParent/Guardian Name* First Last Are you a Member of the Museum & Aquarium?* Yes No Museum & Aquarium members receive discounted rates on camps and educational programs. To learn more about becoming a member, Click here.Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*Alternate/Cell PhoneMedical InformationEmergency Contact Name First Last Relationship to StudentHome PhoneAlternate/Cell PhoneDoes the student have any medical conditions or allergies?* Yes No If you answered yes, please list conditions/allergies below along with any medications.Preferred Physician/HospitalInsurance/Policy #The National Mississippi River Museum & Aquarium/Dubuque County Historical Society (NMRMA/DCHS) has my authorization to obtain necessary medical treatment in the case of any emergency situation that may arise and neither I nor the indicated emergency contact is able to be reached at the time of such emergency. I agree that in no event will the NMRMA/DCHS be held liable for any injuries, accidents or losses suffered by my child/the participant while participating in any supervised programs and the NMRMA/DCHS is hereby released from liability. In addition, my signature authorizes the NMRMA/DCHS to photograph the registered participant for the reasonable use and purpose of promotional advertising for summer camps and other educational classes.* I have read the above statement and agree. Today's Date Program InformationMy student would like to attend the following programs:Pricing: Member Half Day $20/Member Full Day $35 Non-member Half Day $25/Non-member Full Day $40 Friday, September 30 Morning Session - Dino-Mite! Friday, September 30 Afternoon Session - Going, Going, Gone! Thursday, October 20 Morning Session -Fish are Friends (and Sometimes Food) Thursday, October 20 Afternoon Session - Campfire Cooking Friday, October 21 Morning Session - Native Americans Friday, October 21 Afternoon Session - Ways of the West Payment Information Payment must be received to complete registration. Checks can be made payable to "NMRMA". Checks can be mailed to or dropped off in person at: National Mississippi River Museum & Aquarium Attn: Melissa Wersinger 350 E. 3rd St. Dubuque, IA 52001 To pay by credit card, please call 563-557-9545 ext. 213.