Lake Chautauqua Lutheran Center Online Summer Camp Registration

Instructions: Fill out the form below. Any field that is required is marked with an asterisk (*). Once the form is complete, click Submit at the bottom and your registration is complete. (Confirmation Campers please register with your Pastor rather than online.)

* Program Title

* Week Number

* Has the camper participated in an LCLC program before?

Yes

No

Camper Information

* First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

* Gender

* Age

* Birth Date

* Grade completing in June 2010

Cabin Buddy Request (Only one. Requests must be mutual.)

Home Congregation (i.e. First Lutheran, Jamestown)

Pastor

Parent/Guardian Information

Title

* First

* Last

If different from above:

Street Address

Address Line 2

City

State

Zip Code

Phone Number

* Cell/Day/Work Phone

Email Address

Discounts

Please check all that apply. Please see the "Discounts for You" section of our brochure for more details.

Early Bird: Payment in full must be received before 4/5/10. $10 off/mini camper; $15 off for all other

Bring A Friend

Family: $10 off for each additional sibling after the first

Double Dose: $15 off second program's full fee

Friend's Name

Sibling name(s)

Double Dose: list second program choice

Credit Card Information

Save time and paper by paying in full at this time. The minimum fee for online registration is $100.

Please indicate the fees you would like to have charged to your credit card at this time.

* Program Fee

* Camp Store Advance: $15 maximum suggested

* $7 Camper Photo

Yes

No

* Total amount to be charged less discounts from above. ($100 minimum)

* Name on Card

* Credit Card Type

* Credit Card Number

* CSC Code

* Expiration Date (mm/yy)

* Indicates Response Required


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