2014 Centralia Campout Registration Form

If you want to register electronically, and have scanning capabilities, you may print
out this form, fill it out, scan it, email it to me as an attachment, and pay with PayPal below.

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___________________________


# of campers:                                     ___@ $80                                               $__________

# of children 12 and under:                               ___N/C                                                        

My total donation is:                                                                                            $__________

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,
send cash or your check made out to Ray Leach,
then mail to:
Ray Leach
815 W. 6th St.
Centralia, WA 98531

Help us continue to put on this event by donating as much as you can!
Your online donation to CENTRALIA OLD-TIME MUSIC CAMPOUT will be processed by
PayPal, the most widely used and secure internet payment source available.
It's quick and easy.  Simply click on the button below.
(the extra $2 per person is for PayPal's fee to me).

Choose how many campers

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Registration Form In PDF Format