MAD MOON CAMPOUT

CAMP TECUMSEH - BROOKSTON, IN

NOVEMBER 12-14, 2004

CAMPOUT REGISTRATION FORM

Return Form to Your Circle’s Circle Leader

FOR INITIATION

PURPOSES PLEASE

IDENTIFY NEW

DAUGHTERS

CIRCLE	LAST NAME
FATHER’S NAME	Y NAME
1^ST DAUGHTER	Y ADVENTURE GUIDE NAME
2^ND DAUGHTER	Y ADVENTURE GUIDE NAME
3^RD DAUGHTER	Y ADVENTURE GUIDE NAME

Dad and First Adventure Guide	$110.00
Second Adventure Guide (add $50)
Third Adventure Guide	- Free -
Friday Night (add $15.00 per person)
Late Fee (add $20.00 if after 10/22/04)
TOTAL	$

Please make all checks (checks only) payable to:

Elmhurst Y Adventure Guides

Note: You must be registered in the 2004/05 Indian Program.