_______________Summer Camp for Girls______________

Camp Registration Form

Name of Camper:__________________________________________

Parent Names:____________________________________________

Street Address:____________________________________________

City, State, Zip:____________________________________________

Home Phone:_____________________________________________

Work Phone______________________Name___________________

CHOOSE A SESSION:

JUNE 7-11, 2010___________AUGUST 2-6,2010_____________

________________________________________________________________

Age of Camper:_____________________________________________

T-shirt Size: __________

• Each camper may request up to 1 friend attending camp as a roommate OR room assignments will be made according to age.

• A $100 (nonrefundable) deposit is required upon registration and will be applied to the total camp cost of $250.

• Please include a current wallet size school picture with your registration.

Deposit Amount:__________________

(checks payable to: Academie Agencie or credit card)

Type of Credit Card: Exp. Date: _____________________________________________________________

Account Number: ________________________________________________________________________

________________________________________________________________

220 Broadway, Suite B. Fargo. ND. 58102. 701,235-8132 fax 701,235-0027

academieagencie.com