Old Tyme Country School Registration Form 2024

PLEASE PRINT:
Student Name: ___________________________________Age_______ Grade Just Completed________

Name of Parent(s)/Guardian______________________________________________________________

Mailing Address________________________________________________________________________

City: ____________________________________________State:________ Zip:________________

Phone Numbers: Day________________________ Cell________________________

Email__________________________________________________

(Circle One) July 8 thru July 12 July 15 thru 19 July 29 thru August 2
Session I: II: III:

Health Information: Any health conditions we need to know about? (Allergies, daily medication, etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Fee Enclosed: $___________ per student (KHC Members) or $ (Non-Members)

Make Checks payable to Kanabec History Center or pay by PayPal on our website, please add who is
paying, name of students, and contact information for the students records.

Date: ________________________________ Signature: _______________________________________

Submit this form and fee to: Kanabec History Center, 805 Forest Avenue West, Mora MN 55051
Questions call 320-679-1665 or email: center@kanabechistory.org