Camp AsthmaCadabra

campers: Registration Form

Registration Form
 
Name of Child
 
Date of Birth Age Gender
 
Street Address
 
City State Zip
 
Name of Parent(s)/Guardian(s) Email
 
Phone (after 5 PM) County of Residence
 
Signature of Parent/Guardian
 
Name of Child's Physician

FINANCIAL COMMITMENT

Please indicate your desired level of financial support by checking ONLY ONE of the following options:

___ I (We) have enclosed the $25 registration fee AND agree to sell a minimum of ten (10) Camp Lottery tickets at $5/ticket. Details to follow.

___ I (We) agree to sell a minimum of 15 Camp Lottery tickets at $5/ticket. Details to follow.

___ I (We) will speak to Tony Delonti, Camp Director, about other arrangements.

Please send completed form along with the $25.00 non-refundable registration fee per camper (if checked above) by May 5, 2017. NO FORMS WILL BE ACCEPTED AFTER THAT DATE. You will then receive further information. Make checks payable to “Camp AsthmaCadabra” and send to:

Camp AsthmaCadabra
PO Box 1536
Wilkes Barre, PA 18703

For more details please call Tony Delonti, Camp Director at (570) 876-0245 or Lisa Pupa, Camp Coordinator, at (570) 430-6984.

OFFICE USE ONLY
Date Received  
Date Package Sent