Student Registration for Mission San Luis Activities Leon County Gifted Symposium Saturday, April 13, 2013

8:30 a.m. 12:45 p.m.

Participants should be dropped off between 8:10 and 8:30 a.m. and picked up between 12:45 and 1:05 p.m. at the Mission San Luis Visitor Center. Childs Name: Parent/Guardians Name: Address: E-mail Address: Phone Numbers: Name: Home: Cell: Emergency Contact: Phone Numbers: Physician: Home: Name: Home: Cell: Relationship: Cell: Phone: City, State, Zip Code: Date of Birth: Grade:

Explain any special needs or information about your childs medical and/or social history:

List any activity restrictions or precautions:

List any allergies:

I hereby authorize my child(ren), , to participate in all activities sponsored by Mission San Luis. In case of an accident or illness requiring medical treatment, I authorize my child to receive such treatment as the attending medical personnel deem appropriate. I hereby release and agree to hold harmless the Florida Department of State, Division of Historical Resources, Bureau of Archaeological Research, Mission San Luis, Friends of Mission San Luis, and their employees, agents, assignees, and/or other acting on their behalf for any illness or injuries suffered by my child during activities sponsored by them. I give Mission San Luis and the press the right to take and use without payment, any photographs, slides, or films of my child, as may be needed for public relations purposes, marketing/advertising, press releases, Website development, or training purposes. Parent/Guardian Signature: Printed Name: Date:

The registration fee is $7 per participant. The completed registration form and payment must be received by April 1, 2013. Payments may be made by check, credit/debit card, or cash. Please make check payable to Friends of Mission San Luis, or complete the credit card information section on the registration form. Cash payments must be made at the Visitor Services desk. Method of Payment (check one): Check Cash American Express Discover MasterCard Visa

Name on Credit Card: Account Number: Expiration Date: / / Security Code: Same as above City, State, Zip Code: Date: Other (see below)

Billing Address (check one): Address: Cardholders Signature:

Mission San Luis, 2100 West Tennessee Street, Tallahassee, FL 32304 PH: 850-245-6406 FAX: 850-488-8015 programs@missionsanluis.org