Email:
Phone:
440-834-1492
CENTURY VILLAGE MUSEUM
226 years of Geauga County History, ALL in One Place!
14653 E. Park St. ​Burton, OH 44021
PIONEER SCHOOL 51st ANNIVERSARY
July 8 - July 12, 2024
Consider joining our membership to receive a discounted rate on Pioneer School.
This annual program is rapidly approaching fifty one consecutive years and takes place in July every year.
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Each day begins at 10 a.m. and concludes at 3 p.m.
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All activities take place on the grounds of the Society’s Century Village Museum in Burton, Ohio.
The age range for children is 8 to 12 years old.
You can download the registration form below and upload the completed form
Or print this page to mail in or upload
Name
PLEASE PRINT AND MAIL WITH PAYMENT
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SPACE IS LIMITED SO RESERVE YOUR SPOT TODAY!
GEAUGA COUNTY HISTORICAL SOCIETY PIONEER SCHOOL REGISTRATION 2024
July 8-12, 2024 10-3pm
Ages 8-12 years
Cost: $100 for GCHS Members, $120 for Non-Members Please complete the registration form by June 28, 2024.
Make check payable to GCHS and mail with registration to:
Geauga County Historical Society PO Box 153
Burton, Oh 44021 Attn: Pioneer School
Credit card payments can be made over the phone or on our website: centuryvillagemuseum.org.
Please contact our office (440)834-1492 if you need assistance.
*** If you wish you may bring a packed lunch, to meet any dietary needs or requirements, to enjoy lunch on the grounds ***
Child’s Last Name: _______________________ Child’s First Name: ______________________
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Child's Age: __________________
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Child's D.O.B.: ________________
Parent/Guardian Name: ________________________________________________________
Address: ____________________________________________________________
City: ______________________ State: ____________________ Zip: __________________
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Home Phone: ___________ Work Phone: ____________ Cell Phone: ________________
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Email: _____________________________________________________________
Do you grant permission for us to photograph your child for use in our publications?
* Yes * No
Does your child have any special needs or allergies?
If someone other than the Parent/Guardian will be picking the child up please list their full names as stated on their driver license:
Parent Signature: __________________________________________________________
*** If you wish you may bring a packed lunch, to meet any dietary needs or requirements, to enjoy lunch on the grounds ***
*Please complete one form for each child registered*
PERMISSION FOR MEDICAL TREATMENT AND RELEASE OF MEDICAL RECORD INFORMATION
For the week of July 8-12, 2024 I/We, the parent(s)/legal guardian(s) of the child listed below hereby authorize permission for medical treatment of and release of medical record information concerning our child in the event we cannot be reached in an emergency.
(Please print)
Child’s Name: ______________________________________
Home Address : ______________________________________________________________
Home/Cell Phone: ______________________________________________________
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Date of Birth: _______________________________________
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Known Allergies:
Date of last Tetanus/Diphtheria booster: _____________________________
Routine or current medications:
Significant medical problems/conditions:
Physician/Pediatrician: __________________________________________________________
Parent/Guardian: ______________________________________________________________
Parent/Guardian Work/Cell Phone: _______________________________________________
Parent/Guardian: _______________________________________________________________
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Parent/Guardian Work/Cell Phone: ________________________________________________
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Parent/Guardian Signature:
___________________________________________________________________________
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