Twilight Camp Registration

"Centennial Round-Up"

Eastern Skies District Twilight Camp

Monday, June 10 - Friday, June 14 2013
4:00 pm - 8:30 pm

Rorie Galloway Park

Fees paid for Camp are non-refundable and are not pro-rated based on the number of days a Scout attends Day Camp. Fees will not be refunded due to cancellation of camp for weather, or other unavoidable circumstances. Registrations received after Wednesday, May 01, 2013 are not guaranteed a T-shirt or program supplies.

Registration Form

1 Person per Form

We also need:

2 copies of Medical Form #680-001 parts A&B.
Shot record information recorded on Medical Form
Copy of Medical Insurance Card
Adult leaders need Youth Protection Training.

Camp Fees

Early Bird: $85
Regular: $95

Checks made payable to Circle 10
Early Bird Registration is on or before Wednesday, May 01, 2013

Contacts

Wendi Hanna Camp Director 3429 Dublin Trail Mesquite TX 75149 Mb 214-538-7319 Email
Dalinda Montes Program Director 613 Braden Mesquite TX 75149 Mb 214-717-8537 Email	Jim Allen Program Director Mb 214-457-1035 Email

Registrant Information

First Name: Middle Name: Last Name:

DOB: Unit Type: Unit #:

Address: City: State: Zip:

Home Phone: Work Phone: Cell Phone:

Email Address: Gender:

Note Special Medical Needs:

Parent Contact Information

First Name: Last Name:

Address: City: State: Zip:

Home Phone: Work Phone: Cell Phone:

Email Address:

Authorized Transport (if different from Parent above)

Name of person authorized to transport child to/from camp:

Home Phone: Work Phone: Cell Phone:

Email Address: Driver's License Number:

Is there anyone your child cannot be released to? No Yes , if so, who?

T-Shirt Order (One included with Camp Fees, additional shirts are $10 each

Included shirt size:

Additional Shirt @ $25	Age Group:	Size:
Additional Shirt @ $25	Age Group:	Size:
Additional Shirt @ $25	Age Group:	Size:

The various age groups have different colored shirts which are determined shortly before camp. Sorry, we can't offer custom colors.

Not all shirt sizes are available for every age group selection.

Camp Fees

Camper Fee	$85
T-Shirt (1 included)	$0
Additional T-Shirts

Total

Make checks payable to:
Circle 10

Security code from the image above:

If you can't read the code, press here to get a new one.

PHOTO RELEASE. I hereby assign and grant to the local council and the Boy Scouts of America the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me or my child by the Boy Scouts of America, and I hereby release the Boy Scouts of America from any and all liability from such use and publication.

Complete the form, press the submit button, print out the completed form, sign it and deliver it, along with payment to the camp directors.