The Whitby Historical Society Special Event Registration Form -2007
museum@whitbyhistoricalsociety.com 905 556 9822 www.whitbyhistoricalsociety.com
Welcome and thank you for your interest in attending or having your child attend a workshop or special event at the museum.
Your application information is confidential.
Contact Information
Name_________________________________________________________________________________
Address_______________________________________________________________________________
City________________________________________________________________________________
Postal
Code________________________________________________________________________
Home Phone_____________________________________________________________________
Work/Alternate Phone___________________________________________________________
E-Mail Address___________________________________________________________________
Name of Event or Workshop and Date_________________________________________________
Special Needs or Requirements.
Have you reached the age of magority? Children must have the signature of a parent or guardian.
Person to Notify in Case of Emergency
Name
Street Address
City & Postal code
Phone
Fees for Event or Workshop
Amount Enclosed __________________________________________________ Agreement and Signature
Name (please print) ________________________________
Signature______________________________________
Date__________________________________________
By signing and submitting this application, I affirm that the facts set forth in it are true and complete. I agree to hold Whitby Historical Society free of any and all Liability to me or my child as a result of participation in this activity.
Whitby Historical Society Policy:
It is the policy of this Society to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Thank you for completing this application form and for your interest in volunteering with us.
Please return to Whitby Historical Society 123 Brock Street South Whitby, Ontario L1N 4J9