PROSPECTIVE CAMPER FORM

Please fill out this form, and if you have any questions email office@pasquaney.org or call (603) 744-8043.

Name of Prospective Camper(Required)

First Middle Last Suffix

Name Preferred to be Called

Date of Birth(Required)

Parent/Guardian 1 Name(Required)

Prefix First Last Suffix

Name Preferred to be Called

Parent/Guardian 2 Name

Prefix First Last

Name Preferred to be Called

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian 1 Phone(Required)

Parent/Guardian 2 Phone

Parent/Guardian 1 Email(Required)

Parent/Guardian 2 Email

I would like to be placed on the Prospect List for the Summer of

Please contact me about the availability of financial aid for my son.

How did you hear about Pasquaney?

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