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Vine Street Gospel Chapel

1441 E Vine Street

Des Moines, IA  50316

Youth Camp 2012!!  Registration Form

           June 17 – June 20

              YMCA Snow Mountain Ranch

                   1101 County Road 53

                   Granby, Colorado  80446

PLEASE CHECK ONE:         [   ]  I WILL PAY FULL COST       or     [   ]  FINANCIAL HELP NEEDED            

(1)Name:_______________________________________________________________

Age:_________________       Medical needs ie. Allergies, medicine, etc:_____________

(2)Name:________________________________________________________________

Age:_________________       Medical needs ie. Allergies, medicine, etc:_____________

 (3)Name:________________________________________________________________

Age:_________________       Medical needs ie. Allergies, medicine, etc:_____________

 (4)Name:________________________________________________________________

Age:_________________       Medical needs ie. Allergies, medicine, etc:_____________

(5)Name:________________________________________________________________

Age:_________________       Medical needs ie. Allergies, medicine, etc:_____________

_______________________________________________________________________

If more space is needed for Churches, youth groups, or large families; please make additional copies.