REGISTRATION  FORM

 Last Name

 His First

Her First

 Address

City

  State/Zip

 Home Phone

 Chapter

 Good Sam No.

 Exp. Date

 Handicap Permit No.

Registration Fee

Postmarked On or Before

Postmarked  After

Payment Due

4-22-10

4-22-10

 1 Rig ( 2 Persons)

$50.00 (US Funds)

$55.00 (US Funds)

 $

 1 Rig (1 Person)

$42.00 (US Funds)

$47.00 (US Funds)

 $

 Extra Person (12 & over)

$10.00 Each Person

$10.00 Each Person

 $

 Extra Night

Thurs 5/6.

$15.00 Each Night

$15.00 Each Night

 $

$

Make Check Payable To: Washington State Good Sams                                                  
 And Mail To:   Dale Anderson, PO Box 55, Poulsbo, WA 98370-0055

  Total

We understand the Washington State Good Sam Organization has taken reasonable safety precautions and we accept full responsibility for the welfare of our units and all persons in our unit while attending the Washington State Campout.

Date Received

 Check No.

Total

Owe

Need Refund

 Check

 Date

 Cash

 Initial