Name: ___________________________ M/F: ___ Age: ____ Birthdate:_____

Mailing Address: _________________________________________________

City: ________________________ State: ____ Zip: _________

Parent/Guardian: ________________________________________________

Evening Phone: ____________________ Daytime Phone: ________________

Dates Attending: You are encouraged to attend for all three days!

____ June 24 ____ July 8 ____ July 22

____ June 25 ____ July 9 ____ July 23

____ June 26 ____ July 10 ____ July 24

____ August 12 ____ August 19

____ August 13 ____ August 20

____ August 14 ____ August 21

Lunch Program (optional):

We’ll be glad to make a healthy, fresh lunch for you! Just add $3.50 per day and indicate below which days you want it!

____ June 24 ____ July 8 _____ July 22

____ June 25 ____ July 9 _____ July 23

____ June 26 ____ July 10 _____ July 24

____ August 12 ____ August 19

____ August 13 ____ August 20

____ August 14 ____ August 21

Extended Hours (optional):

We are offering extended hours for campers from 8 am – 10 am and again from

3 pm – 6 pm as needed for a fee of $3.00/hr. Extended hours needed:

____ June 24 hrs_____ ____ July 8 hrs _____ ____ July 22 hrs _____

____ June 25 hrs _____ ____ July 9 hrs _____ ____ July 23 hrs _____

____ June 26 hrs _____ ____ July10 hrs _____ ____ July 24 hrs _____

____ August 12 hrs_____ _____ August 19 hrs_____

____ August 13 hrs_____ _____ August 20 hrs_____

____ August 14 hrs_____ _____ August 21 hrs_____

Payment: Camp tuition ($20/day or $50 3-day week): __________

_____ Enclosed is my check payable to Wildlife Safari.

_____ Please charge my credit card (Visa or Mastercard)

Cardholder name: _______________Card # ______________Exp date: ______

For more information, call Tammie at 541/679-6761, ext 227.