Family registration

Registration Form - Family Retreats

Please print registration form (one form per person) and fax to 863.696.1062
If you prefer, you may fax your registration form and pay on-line using our secure server.
(Just use the Registration box for fees to be paid - it will appear as a 'donation' but it is a payment)

Mother/Daughter or Father/Son Registration

Adults Name:_____________________________________________________

Childs Name(s):___________________________________________________

Age(s):_____________________________________________________

(All ages are welcome. However, past participants recommend at least 4 years and up as activities are geared more to interactive ages. Child - 5-18 years old. Call or email for rates under 5 years of age.)

Address:__________________________________________________________

____________________________________________________________

City:______________________________ St:_ Zip:_______________

Phone: (include area code)____________________________________________

email address:______________________________________________________

Home Church/City:__________________________________________________

___Mother & Daughter Retreat       October 5-6, 2012 ($53 adult/$37child)
_ Sponsor a table decoration in a "WILD" theme (You will be given instructions)
_Father & Son Lakeside Retreat      Nov. 16-17, 2012 ($53 adult/$37child)
_ Paintball Option: Add $15 and Waiver Signature
___Optional Camp Out Extension        Nov. 18-19 Add: ($28 adult/$17 child)

$ Amount Enclosed:_______________________ $45 deposit per retreat or full payment.

Charge to: Mastercard Visa American Express Discover
(3% surcharge when using a corporate account credit card)

CC #________________________________________________exp. date

Authorized Signature:____________________________________________________

Billing address of cardholder if different from above:
Street:____
City:
ST:_Zip:_
Phone of card holder: ____________________

Deposit is transferable but not refundable.