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Children/Youth Registration Form (One registration form per child, per camp program. Please photocopy/print as needed) |
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| Last Name | _________________________________ | ||
| First Name | _________________________________ | ||
| Address | _________________________________ | ||
| City/State/Zip | _________________________________ | ||
| Phone | _________________________________ | ||
| Parent's work phone: | _________________________________ | ||
| _________________________________ | |||
| Would you be willing to receive confirmation materials via email? yes no | |||
| Current Grade (04/05) | _________________________________ | ||
| Birth date (mm/dd/yy) | _________________________________ | ||
| Home Church | _________________________________ | ||
| Church City & State | _________________________________ | ||
| Sex (circle one) | M F | ||
| Parent(s)/Guardian | _________________________________ | ||
| Camp Program Desired | CHILDREN GO WHERE I SEND THEE | ||
| Total Enclosed) | $________________________________ | ||
| Check #) | _________________________________ | ||
| Check here to request financial aid. For Financial Aid Information - click here | |||
| Check here if you do not wish any pictures of your child to be used in publicity materials | |||
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Mail registration form with check to: Camp Lutherhaven, 1596 S. 150 W. Albion, IN 46701 |
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