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REGISTRATION FORM

I am registering my child for:

Please complete this form and return it to the following address. If you are registering more than one child, please use one form per child

Environmental Resource Center P.O. Box 819 Ketchum, ID 83340 Name of Participant:

[ ] Male

Grade for 2011-12 School Year:

[ ] [ ] [ ] Discounts

[ ] Female

[ ]

- $35

- $25

[ ]

THEN, also take Family Discount (for multiple family members, or one child in two camps; only one discount per family) if applies

-$50

Scholarship [ ]

Emergency Contact Name:

T-Shirt Size:

ERC Family Membership Discount

Early Bird Registration Discount Before May 1

Parent/Guardian Name:

[ ]

Relationship to Participant:

Give or Receive Scholarship Assistance I would like to receive scholarship support information and I am enclosing my $50 deposit (per camp to hold space) We would like make a donation to help out another family send a child to EcoCamp Payment Total

[ ] No

Make sure your cabinmate also requests you. We will do our best, but there are no guarantees.

Cabinmate Request:

$350

[ ]

City, State & Zip:

[ ] Yes

$430

OR

Mailing Address:

Has child attended EcoCamp before?

$350

Choose ONE from section in gray, if applies

Phone Number:

Email Address:

Phone:

EcoCamp: Chasing Wild (for rising 4th-7th graders, July 18-22) EcoCamp: Adventure Aquatic (includes river rafting trip Friday) (for rising 4th-7th graders, July 25-29) EcoCamp: Night Stalkers (for rising 4th-7th graders, Aug 8-12)

Youth:

[ ] Small

[ ] Medium

[ ] Large

Adult:

[ ] Small

[ ] Medium

[ ] Large

Payment Method Name on Card:

[ ] XXL

Dietary or Medical Restrictions:

City, State & Zip: E-mail Address for Receipt: Credit Card Number:

Please mark how you heard about EcoCamp – Newspaper ad Newspaper article ERC Mailing or Newsletter BCSD Bridges Attended Last Year ERC website Sun Valley Online School Flyer Other (please describe)

$ $

[ ] Check [ ] MasterCard [ ] Visa [ ] AMEX [ ] Discover

Card Billing Address: [ ] XL

$50

3-digit Security Code from back of card:

Expiration Date:

Signature: Payment plans may be available. Contact Lisa Horton at 208.726.4333


Registration 2011