First Name:     Last Name: 

Current Grade :  DOB:      

Male  Female      Camper Phone:

Street Address:   Apt:

City:   State: ALABAMA ALASKA ARKANSAS ARIZONA CALIFORNIA COLORADO CONNECTICUT DELAWARE FLORIDA GEORGIA HAWAII IDAHO IOWA ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MISSOURI MINNESOTA MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NEVADA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING    Zip Code:

Camper Email:

Church Name: (if applicable)

Roommate Request:

PARENT/GUARDIAN INFORMATION:

First Name:    Last Name: 

Home Phone:         Work Phone: Ext.:

Cell Phone:     Email Address:

SECOND PARENT/GUARDIAN INFORMATION:

First Name:    Last Name: 

Home Phone:      Work Phone: Ext.:

Cell Phone:    Email Address:

PAYMENT OPTIONS:

Registration is not confirmed until full payment has been made.

Price: $109

Discount Price: $89 if registered and paid in full before January 15th, 2007

How would you like to make your payment?:

Credit Card over the phone (you will be contacted within the next week)

Send in check by mail or drop off within one week of online registration  

P.O. Box 1264 Canby, OR 97013

Please Note:

Cancellation Policy - Cancellation of attendance of the retreat must be given no later than Feb 1st for a 50% refund. No refund given if attendance is cancelled after that date.

First Name:     Last Name: 

Street Address:   Apt:

City: State: Zip:

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Questions and Comments:

When is the best time to contact you in order to take care of payment? (Available hours for us to call: Mon-Fri 8am-5pm)

If you are having difficulty and would like to contact the camp registrar by e-mail click here