Name:_______________________________________________________________

Address:_____________________________________________________________

City:____________________

State:_______

ZIP:________

E-mail address:_______________________________________

Phone: (____)___________________

Boy:______

Girl:______

Age at Camp:____

Birthdate:________

Grade Complete 6/04:_____

Parent's Names:________________________________________

Check One:

____My child will need to leave camp - day/explanation:_________________

____My child will not need to leave camp before check-out

Check One:

____ I will be picking up my child on Saturday

____My child will go home with__________________________

Class Selections (Choose four you want + one alternate - class sizes are limited)

Indicate alternate with an "A"

__Archery	__Drama/Skits	__Scrapbooking
__Clay	__Ductigami	__Senior Posters (grades 9-11)
__Crafts	__Guitar (bring a guitar)	__Song Leading (for boys)
__Cross Stitch	__Model Rockets	__Woodworking

Check One:

___Enclosed is $25.00 reservation fee. Balance due June 1st.

___Enclosed is $150.00 for the complete fee for my first child.

___Enclosed is $135.00 for the complete fee for my additional child.

___Late fee $10.00 for each camper, if paid after June 1st.

___Yes, I would like to purchase a camp t-shirt. Enclosed is $10.00.

Adult Size: ___Small ____Medium ____Large ____1X ___2X