Taconic Retreat & Conference Center ť Register Online

Select Your Session!*

Summit Week (Ages 12-18) June 30-July 6, 2013
Discovery Week (Ages 8-12) July 7-13, 2013
Los Campeones de Dios (Ages 8-12) July 21-27, 2013

$200 per session + $50 non-refundable registration fee

Camper's Name:*

Street:*

City:*

State:*

Zip:*

Home Phone:*

Birth Date:*

Grade Completed:*

Camper's Home Church:

Parent E-mail Address:

Cabin Mate Preference:

Father's Name:

Address:*

Cell Phone:*

Work Phone:

Mother's Name:*

Address:*

Cell Phone:*

Work Phone:

With Whom does the Camper Reside?:*

People authorized for camper pick-up (Must list two):*

Relation to Camper:*

Cell Phone Number:*

Emergency Contact (not parent):*

Relationship:*

Home Phone Number:*

Cell Phone Number:*

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