Name of Camp: ________________________________

For period of (please give your choices):
1st: ______________________ to ______________________
2nd: ______________________ to ______________________
3rd: ______________________ to ______________________
Preferred location at camp (if applicable):
1st: ________________________________
2nd: ________________________________
3rd: ________________________________

Names
(Please attach separate sheet
with additional names.)		 AMC Membership
(Number and type
if applicable.)		 Age (if under 21
as of July 1.)
1. _____________________________________________________________
2. _____________________________________________________________
3. _____________________________________________________________
4. _____________________________________________________________
5. _____________________________________________________________
6. _____________________________________________________________

Address ___________________________________________________________
City _______________________ State _________________ Zip ________
Home Phone __________________ Work Phone __________________
Email ______________________________  
License Plate no. _________________
Registration Fee Enclosed $_________________
MC/Visa _______________________ Exp. date _____________  
(Not accepted at all facilities; check camp descriptions, www.outdoors.org/lodging/camps/)

Self-addressed stamped envelope enclosed? Yes ______ No ______
Can you provide transportation for someone else in your area? Yes ______ No ______
Do you need transportation? Yes ______ No ______
Launch time desired (Three Mile Island only) ___________________

Signature: ____________________________________
Date: ____________________________________