Complete the form below and a reservation agent will confirm your reservation by email or phone.

1. MEMBERSHIP INFORMATION

Are you a MODS member? I am not a current MODS Member I am currently a MODS Member
If you are a member, please add the following information:
ID #

Expiration date:


2. PARENT INFORMATION

Name:

Address:

City:

State:

Zip:

E-mail:

Phone # Daytime:

Evening:


3. CHILD INFORMATION (Please submit additional forms to register additional children)
Child's Name:

Age:

Birth Date:

Emergency Contact:
Name:

Relationship to Child:

Phone # Daytime:

Evening:

Cellular/Beeper/Other Phone #

Any special information (medication, etc.)

4. PROGRAM INFORMATION
1st choice:
Program Name:
Date:Fee:
2nd choice
Program Name:
Date:Fee:
3rd choice
Program Name:
Date:Fee:
4th choice
Program Name:
Date:Fee:
Subtotal:

Before/After Care Fees ($5.00 per day, per child)

Grand total:


5. PAYMENT INFORMATION
Credit card #

Credit card type:
Specify your credit card type Visa MasterCard American Express
Name as it appears on credit card:

Expiration date:


6. OTHER WAYS TO REGISTER
By Phone: 954.713.0930
By Fax: 954.467.0456
By Mail: Museum of Discovery and Science, Attn: Camp Reservations
401 SW Second Street, Fort Lauderdale, FL 33312