JUNIOR DOCENT PROGRAM
   Parent / Guardian Form

Applicant's Name:_________________________________________     Date: ________________________

Parent / Guardian Name(s): _________________________________________________________________

Address:_____________________________________________________________ZIP:_______________

Phone: Home: _____________________    Cell: ____________________    Work:______________________

Parent's E-mail: ________________________________________

Child's E-mail: _________________________________________


1. Who can we contact in case of emergency other than Parent / Guardian:?

     Name: __________________________________     Telephone: _________________________

2. Does the applicant have any allergies or other special medical or physical needs?

3. May we have your permission to use photographs of your child to promote Desert Museum programs?

4. If selected, your child will be coming to the Museum an average of twice per month for two years.

     a) Will you have reliable transportation to the Museum?    Yes  No

     b) Are you interested in carpooling?     Yes   No        Closest major intersection:

     c) Are you committed to follow through with such a program? Yes   Maybe