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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. 

Each day begins at 10 a.m. and concludes at 3 p.m. 

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

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PLEASE PRINT AND MAIL WITH PAYMENT

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: ______________________

Child's Age: __________________

Child's D.O.B.: ________________


Parent/Guardian Name: ________________________________________________________


Address: ____________________________________________________________


City: ______________________   State: ____________________ Zip: __________________

Home Phone: ___________ Work Phone: ____________     Cell Phone: ________________

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: ______________________________________________________

Date of Birth: _______________________________________

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: _______________________________________________________________

Parent/Guardian Work/Cell Phone: ________________________________________________

Parent/Guardian Signature:

 

         ___________________________________________________________________________

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