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KLUBS INC.

                                                                           ________________ ENTERING GRADE _____ (in Sept.)
DATE OF BIRTH ___/___/___ AGE _____ Sex ______ Home Phone _____________ Cell_____________
WORKPHONE/Cell (F) _____________________ WORKPHONE/Cell (M) ______________
PARENT NAME(S)_______________________________________________________________
MAILING ADDRESS___________________________________CITY/ST________________ZIP________
CABIN MATE REQUESTS: _______________________________________________________
(Requests for Cabin Mates should be sent in together. No more than 2 requests!!)
 
TOTAL COST: $132 Make checks payable to:
CIRCLE YOUR PLAN A $50 due with registration ($20 non-refundable),
PAYMENT PLAN: $42 due by May 15, remainder of $40 due first day of camp.
PLAN B $50 due with registration ($20 non-refundable),
$82 due first day at camp.

RETURN THIS FORM TO: with $50 registration fee
Box 163, Malden IL 61337