I am registering my child for:
REGISTRATION FORM 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 2012-13 School Year:
[ ] Female
Phone Number:
[ ]
City Meets Wild (Day Camp) (No discounts below) (for rising 4th-6th graders, July 16-20) (Rate member/non-member)
$200/ $250
[ ]
EcoCamp: Forces of Nature (includes river rafting trip Friday) (for rising 4th-7th graders, July 23-27)
$430
[ ]
EcoCamp: Flight School (for rising 4th-7th graders, Aug 6-10)
$350
[ ]
Science on the Summits—NO RAFTING (for rising 8th and 9th graders, July 23-27)
$350
[ ]
Science on the Summits—WITH OPTIONAL RAFTING (for rising 8th and 9th graders, July 23-27)
$430
Choose ONE from section in gray, if applies
Discounts
Email Address:
[ ]
ERC Family Membership Discount
- $35
OR
Mailing Address: [ ]
Early Bird Registration Discount Before May 4
- $25
[ ]
THEN, also take Family Discount (for multiple family members, or one child in two camps; only one discount per family) if applies
-$50
City, State & Zip: Parent/Guardian Name:
Scholarship
Emergency Contact Name: Phone:
Relationship to Participant:
Has child attended EcoCamp before?
[ ] Yes
[ ] No
Give or Receive Scholarship Assistance
[ ]
I would like to receive/have attached a scholarship application and I am enclosing my $50 deposit (per camp to reserve a space)
[ ]
We would like make a donation to help out another family send a child to EcoCamp
$50 $
Make sure your cabinmate also requests you.
Cabinmate Request:
Payment Total
We will do our best, but there are no guarantees.
Youth:
[ ] Small
[ ] Medium
Adult:
[ ] Small
[ ] Medium
[ ] Large
Payment Method
[ ] Check [ ] MasterCard [ ] Visa [ ] AMEX [ ] Discover
T-Shirt Size: [ ] Large
[ ] XL
[ ] XXL
Dietary or Medical Restrictions:
Name on Card: Card Billing Address: City, State & Zip: E-mail Address for Receipt:
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)
Credit Card Number: Security Code from back of card:
Payment plans may be available. Contact Lisa Horton at 208.726.4333
Signature:
Expiration Date:
$