Name of Parent

Address

City State Zip

Telephone (Area code) Number

Email

Grade in Fall Boy Girl T-shirt size

Permission to use my child's picture on promo media yes no

Permission to play paintball yes no

Permission is granted for emergency medical care for my child yes no

Full Registration Fee

Resident Camper- $228.00 (includes reg., 6 nights lodging, 18 meals, & T-shirt)

Day Camper- $105.00 (includes registration, 7 meals, & T-shirt)

Optional Fees

Paintball $20.00 per session

Ceramics $20.00

Leathercraft $20.00

Please send your camp deposit or payment to:

Shepherd Staff Inc.
Attn. Registrar
Box 70
Rexford, KS 67753

Indicate that it is for the "Creative Arts Camp"

Thank you!