Windsor History Summer Workshop Registration Form

Child’s name:                                                                                                                                    

Name of Parent/Guardian:                                                                                                              

Address:                                                                                                                                             

City:                                                                                          State:               Zip:                         

Home phone:                                                   Work phone:                                                           

Cell phone:                                                       Household email:                                                   

Child’s Birthday:                                 Age:                 Child’s School:                                           

Grade or equivalent in fall 2009:                   Sex (check one): □ Male   □ Female

A $25 non-refundable deposit is due to register for the program. The balance is due by July 17, 2009. 

Total enclosed: $                                                                                

Make checks payable to the Windsor Historical Society.

Credit card type: ____________________

Credit card number:                                            __________   Expiration date:                            

3 Digit Card Security Code: _____________ 

(On the back side of card.  It appears after and to the right of your card number.)

Signature:                                                                                                                   

Please send registration and payment to:

Windsor Historical Society, 96 Palisado Avenue, Windsor CT 06095