NH Audubon - New Hampshire Audubon

2011 NH Audubon Summer Camp Registration FormDirections: Please register one camper per form. Registration opens March 14 for NH Audubon members & March 21 for nonmembers.This form may be printed and submitted to NHA Summer Camp Registration, 84 Silk Farm Road, Concord, NH 03301(fax: 226-0902) or completed electronically, saved, and emailed to shall@nhaudubon.org1. Select a camp location: □ Massabesic Center, Auburn □ McLane Center, Concord2. Complete camper information below:Child’s Name: _________________________________________________________________Date of Birth: ___________ □ Boy □ Girl Grade completed in June 2010: ____Street Address: ________________________________________________________________Town: ________________________________ State: _______ Zip: _____Parent Name: _________________________________________________________________Daytime Phone Number: _____________ Email Address: __________________________________________3. Select session(s):Sessions Wonders (ages 4-5) Discovery (ages 6-9) Explorers (ages 10-12)#1: June 27 – July 1 □ $110 □ $220 □ $275#2: July 5– 8 (* 4 days) □ $160 □ $220#3: July 11 –15 □ $110 □ $220 □ $275#4: July 18 –22 □ $220 □ $275#5: July 25 –29 □ $110 □ $220 □ $275#6: August 1–5 □ $220 □ $275#7: August 8–12 □ $220 □ $2754. Calculate payment: TOTAL COST OF SESSIONS = $_________If applicable, select discount below. (Only one box should be checked.)□ I am not a member of NHA, but am registering more than one child in my family for camp today. (5% off total)□ I currently have (or am purchasing below) an NHA family membership and only registering one child. (10% off total)□ I currently have (or am purchasing below) an NHA family membership and am registering more than one child in myfamily for camp today. (15% off total)Discount Amount (if applicable) ($_________) 5. Make payment:Payment method: □ Online at nhaudubon.org (via PayPal)SUBTOTAL$_________□ Mastercard □Visa □ CheckFamily Membership ($55) $_________Checks payable to NH Audubon.Donation to Campership Fund $_________TOTAL$_________Credit Card Number: ___________________________(Full payment must be made if total above is $350 or less.If $351 or more, a $200 deposit is required.)Cardholder Name: _____________________________Expiration Date: _______Deposit$_________BALANCE DUE$_________ 6. Next Steps: Please note that your registration process isincomplete until:A. All balances are paid (no later than June 13, 2011) ANDB. Camper info & medical forms submitted (check one below)□ I will download my forms at nhaudubon.org.□ I prefer to receive paper forms in the mail.□ I prefer to receive electronic forms by email.Confirmation and forms will be sent no later than 2 weeks afterregistration is received.