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Children/Youth Registration Form
(One registration form per child, per
camp program. Please photocopy/print as needed) |
| Last
Name |
_________________________________ |
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First Name |
_________________________________ |
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Address |
_________________________________ |
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City/State/Zip |
_________________________________ |
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Phone |
_________________________________ |
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Parent's work phone: |
_________________________________ |
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E-mail |
_________________________________ |
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Would you be willing to receive confirmation materials via email?
yes
no |
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Current Grade (04/05) |
_________________________________ |
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Birth date (mm/dd/yy) |
_________________________________ |
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| Home
Church |
_________________________________ |
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Church City & State |
_________________________________ |
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| Sex
(circle one) |
M
F |
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Parent(s)/Guardian |
_________________________________ |
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| Camp
Program Desired |
CHILDREN GO WHERE I SEND THEE |
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| Total
Enclosed) |
$________________________________ |
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| Check #) |
_________________________________ |
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Check here to request financial aid.
For Financial Aid Information -
click here |
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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 |
