2007 Wings Camp

Pre-Registration Form

Child's Name: ____________________________________  Age: ____________  Date of Birth: __________________

Address: _______________________________ City: ______________________ State: _________ Zip: __________

Phone: ____________________________ Name Child Goes By: __________________________________________

Name of Parent or Legal Guardian: _________________________________________ Phone: ___________________

Name of Person Who Died: _________________________________________ Date of Death: ___________________

Relationship of Deceased to Camper: ________________________________________________________________

Cause of Death: ________________________________________________________________________________

Child's School: ______________________________________ Guidance Counselor: __________________________

Legal Guardian's Signature: _______________________________________________ Date: ____________________

         Mail Completed Pre-Registration Form To:

3HC, Wings Camp

2402 Wayne Memorial Drive

Goldsboro, NC 27534

Please note that space is limited to 30 children.

To ensure your child's space at camp, please return this form as soon as possible!