Lola Broomberg: Counseling, Performance, Social Action, Eugene and Springfield Oregon

2012 imagine That Registration Form

To Register for imagine That! please fill out all the fields in the form below and click the "Register" button at the bottom.

	Camp Information
	Camp Date		Sorry- All the registrations for imagine That! 2012 are filled.
			People who pay for camp before May 1st are entitled to a $10 discount. This will be made available to you on the first day of camp in the form of two hours of childcare and a free t shirt or a direct $10 refund.

	Student Information
	Student's Name
	Address
	City		Zip
	Grade
	Age
	School

	Medical or Special Concerns:


	Parent/Guardian Information
	Name
	Home Phone
	Work Phone
	Emergency Contact Name
	Emergency Contact Phone
	Email

	Any Other Parent Info We Should Know