Loving Hands Ranch - Registration Form

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Camper's Name  

Age ________       Male or Female
                    (circle one)

Birth date  _____________________
               day/month/year

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Parent's Name / Guardian's Name

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Address

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City , State, Zip

_____________________________           _____________________________________   
Phone Number                  E-mail Address if available    

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Signature of Parent/Guardian

_____________________________           _____________________________________   
Emergency Contact Person      Emergency Phone Number

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Work Phone Number   

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Person who will be picking up the camper at the end of camp.

2012 Camp Selected:
    Camp 1 CODA ages 6 - 18  (June 12 - 16)
    Camp 2 Deaf Teens ages 12 - 18  (June 22 - 26)
    Camp 3 Deaf Children ages 6 - 11  (June 27 - July 1)
    Camp 4 Special Needs Deaf all ages  (July 3 - 7)

Ages are somewhat flexible.  Contact Roy Woodall for further details.
Cost is $130 for one camper and $65 for each additional sibling.
Make checks payable to Loving Hands Ranch.

Please list all allergies:

Please list all medications:

Please list any other disabilities or any special needs:

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