2009 Centralia Campout Registration Form

(Print out this form.)

Name(s)_______________________________     _______________________________     _______________________________

Name(s)_______________________________     _______________________________     _______________________________

Please indicate children’s ages.

Street address, Apt No. or P.O. Box Number, City/State/Zip

________________________________________________________________________________________

Home Phone___________________Cell Phone_________________ Email___________________________________________________

# of Campers:                                     ___@ $50                                               $__________

Children 12 and under:                               ___@ Free!!                                                        

My total donation is:                                                                                            $__________

I want to be included on a participant's list so other campers who attend the COTMC may contact me.  (circle one)   Yes        No

I will be bringing Fido.  (circle one)   Yes        No

Estimated arrival date:________________               Estimated departure date:________________

Car Make/Model______________________________        License Plate #/State________________

Print out this form,
attach your check made out to Ray Leach,
and then mail to:
Ray Leach
815 W. 6th St.
Centralia, WA 98531
If you choose to use PayPal, please add $2.00 for every $50.00 donated (to cover their fee to me) Thanks!
Your donation to CENTRALIA OLD-TIME MUSIC CAMPOUT will be processed by PayPal,
one of the most widely used and secure Internet-payment sources available.

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