Last Name __________________________________________________________

Camper Name _____________________________________________ Sex _______

Camper's E-Mail Address ________________________________________________

Address ____________________________________________________________

City _________________________________________________ ZIP ___________

Telephone ______________________________________ Birthdate _____________

School ______________________________________________ Grade ______



Mother _______________________________________ Work Phone _____________

Cell ______________________________ Pager _____________________________

E-Mail Address ________________________________________________________



Father ________________________________________ Work Phone _____________

Cell ______________________________ Pager _____________________________

E-Mail Address ________________________________________________________

Registering for (check all that apply):

__ Winter Travel Day Camp             Deposit Due of $60 __ Overnight Ski Camp             Deposit Due of $110 __ Magic Mountain Overnight             Deposit Due of $50 Based on corresponding deposit amounts noted above, enclosed is check number __________ made out to Youth Services from Mars for $ __________. I understand that the balance payment is required by November 30th. [Deposit is non-refundable, unless camp is full when application is received.]

__________________________________________________ signature

________________ date

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