Children/Youth Registration Form
(One registration form per camper, per camp program.
Please photocopy/print as needed)
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| Last Name |
_________________________________ |
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| First Name |
_________________________________ |
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| Address |
_________________________________ |
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| City |
_________________________________ |
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| 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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| Current
Grade (03/04) |
_________________________________ |
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| Birth date |
_________________________________ |
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| Home Church |
_________________________________ |
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| Church City |
_________________________________ |
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| Sex
(circle one) |
M F |
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| Parent/Guardian
(first, last) |
_________________
_______________ |
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| Camp
Program Desired |
(eg.
Clubhouse G) |
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| 1st
Choice |
_________________________________ |
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| Alternate
Choice |
_________________________________ |
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| Roommate
Preference |
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| 1st
Choice |
_________________________________ |
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| 2nd
Choice |
_________________________________ |
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| Counselor
Preference |
_________________________________ |
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| Total
Enclosed |
_________________________________ |
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| Check # |
_________________________________ |
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Mail to: |
| Check here to have a |
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|
Camp
Lutherhaven |
| financial aid packet |
|
|
1596 S.
150 W. |
| sent to you |
|
|
Albion,
IN 46701 |
| Financial Aid Info - click here |
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| How
did you first hear about Camp Lutherhaven? |
|
Friend/Family
Internet
School/Church
Other_____________________________________ |
