Return this form with payment (U.S. funds) to: Continuing Education/Summer Programs, Raymond Hall 206, 44 Pierrepont Ave., SUNY Potsdam, Potsdam, New York 13676, or fax: (315) 267-3088. Registrations using MasterCard or Visa will also be taken by phone at 1-800-458-1142 or (315)267-2167. Make check payable to: SUNY Potsdam. A non-refundable deposit of $50 is due with this form; the balance of payment is due on June 27, 2003.
Name Age
Birthdate Grade in Sept. 03
Address City/State
Zip
Camper's Home Phone
Emergency Phone No. during camp
Please check: Male Female Resident Commuter
Roommate Request:
1.
Campers must request each other. We try to honor all roommate requests. Doubles only.
School Name of Coach
Check
Mastercard Visa Card # Expiration Date
Please mail __ an additional brochures for my friends to:___________________
_____________________________________________________________
How did you learn about this camp? __________________________________