Museum Expedition 35 Application and Personal Data Form Please Print or Type Name______________________________________________________ Age________ Sex_______ Grade Completed__________ Mailing Address____________________________________________________________________________________________ City __________________________State_________ Zip_______________ E-mail ______________________________________ Home Phone (_____)__________________ Work Phone (_____)__________________Cell (_____)________________________ Parent/ Guardian _________________________________________________Phone (_____)_______________________________ YOU MUST ARRANGE FOR SCHOOL CREDIT IN ADVANCE WITH YOUR SCHOOL COUNSELOR! Do you want educational credit for Expedition 35? ____No ____Yes
Please complete the following information
High School ________________________________School County /District__________________ Principal____________________ School Mailing Address ___________________________________City _________________State _______ Zip_________________ Teachers, do you want to earn Continuing Education Units or Professional Development Hours? ______Yes ______No I wish to register for the following week(s): Legacy Teacher Workshop (Teachers and Educators): June 12-14 _____ Middle School Camp (6th, 7th, 8th Grades): June 17-22 ____
High School Camp (9th, 10th, 11th, 12th Grades): June 24-29 _____
Expedition Fees Total Cost: $350 per week ***All participants must pay a $50 deposit to hold reservations*** Ask about Museum Members Discount
Method of payment: Check /Money order payable to: The University of Alabama Amount Enclosed:_______ Please charge my account: Visa Master Card Discover Card
Balance Due:_________
Name (please print) ____________________________________________________________________________ Card #___________________________________________________________Expiration date______________ Signature___________________________________________ Phone (_____)___________________________ **Your balance is due by May 31, 2013 ** Please return this form to:
Expedition 35 Alabama Museum of Natural History P.O. Box 870340 Tuscaloosa, Alabama 35487-0340
I, have read and understand the enclosed materials and agree to abide by the letter and spirit of the Expedition rules (see enclosed Memorandum. (For participants under the age of 18, a parent or guardian must also sign. _____________________________________ ___________________________________________ _______________________ Expedition Participant Parent or Guardian Date Call (205) 348-9482 or email museum.expedition@ua.edu for more information.