CAMPKINGFISHER

WINTER BREAK2011-2012 REGISTRATION FORM

~~Please fill out one form per child~~

Child’s Name:

Birth date: ___ Gender: Male Female

MM/DD/YY (circle one)

School: ______Current Grade:

Parent/Guardian Name:

Phone: home______work______cell______

Address:

City: State: Zip:

Email:

Please place my child in a group with(up to 2 names, no guarantees)______

We encourage our camp families to become CNC members. To become a member today and pay camp fees at the member price, simply add $80 for CNC Family Membership to your total.

A CNC Family Membership Includes: Unlimited free admission to CNC for one year, guest passes for

6 people($48 value),discounts at the NatureCenter store, reduced fees on select CNC programs including

CampK (allcamps), early registration toCampK, CNC newsletters, CNC emails and more!

We already have a Membership to the Chattahoochee Nature Center

CNC Membership #:______

(Membership must be current through last day of camp)

Which camp(s) will your child be attending?

December Session: December 28 – 30, 2011

 Full-day CNC MEMBER $180  Full-day NON-CNC MEMBER $200

January Session: January 2-4, 2012

 Full-day CNC MEMBER $180  Full-day NON-CNC MEMBER $200

TOTALS:

CNC Membership:______(This $80 is optional but allows you to pay member prices today)

CampScholarship Fund:______(Even a small donation will help send children who otherwise might

not have the opportunity to attend)

Session fees:______

TOTAL ENCLOSED: ______

Method of Payment*Check to CNC Charge*(circle one) MC VISA AMEX DISC

Credit Card #*______Expiration Date ___

Security code ______Signature ______

«If you do not receive confirmation within 5 days, we have not received your registration»

Let’s Go GREENER! We would like to e-mailyour receipt, parent packet and health form to you

YES! Let’s be greener! Send papers by e-mail  No thanks, send papers by regular mail

Questions? Contact us at 770.992.2055 x222 or

*We also accept credit card numbers byphone. We must have your cc # within 48 hours of receiving your registration in order to hold your place.