Sign up Form

S.I. Burn Camp Pre-Registration!

Campers Name:

Street Address:

City:     State:

Zip Code:

Phone Number:

MaleFemale

Age:    T-Shirt Size

Please check this box if your child has attended a camp for burned children before!

If so where?

Will your child need transportation to camp?yesno

Name of Parent/Guardian

E-Mail Address:

This page created & maintained byMidAmerica Net®2000

Web Space donated by LocalLink