NAME____________________________________________________       AGE _____________

ADDRESS_________________________________________________  PHONE _____________

                 _________________________________________________          ZIP _____________

PARENT/GUARDIAN'S NAME _____________________________________________________

HOME PHONE__________________________   WORK/CELL PHONE _____________________

ASSEMBLY ______________________________  CURRENT OFFICE _____________________

MOTHER ADVISOR'S SIGNATURE _________________________________________________
        *No registrations will be accepted without signature
.
T-Shirt SIZE________________________________ (S, M, L, XL, XXL, XXXL)

Please include $85.00 payment to "Grand Assembly Camp Fund"  with registration.
Mail to:  SHERRY SMITH  302 GRANDVIEW DR   NORMAL  IL  61761
 
 

NAME____________________________________________________       AGE _____________

ADDRESS_________________________________________________  PHONE _____________

                 _________________________________________________          ZIP _____________

PARENT/GUARDIAN'S NAME ____________________________________________________

HOME PHONE__________________________   WORK/CELL PHONE _____________________

ASSEMBLY ______________________________  CURRENT OFFICE _____________________

MOTHER ADVISOR'S SIGNATURE _________________________________________________
        *No registrations will be accepted without signature.
.
T-Shirt SIZE________________________________ (S, M, L, XL, XXL, XXXL)

Please include $85.00 payment to "Grand Assembly Camp Fund"  with registration.
Mail to:  SHERRY SMITH  302 GRANDVIEW DR   NORMAL  IL  61761