Breakaway Camp 3 Hold Form

Did your church attend Tall Timbers for camp before this year?*

Yes
No

Church Name / City / State*

Church Name*

Church Billing Address*

Street Address City State ZIP Code

Church Phone*

Church Email (if no email, type none)*

Are you a NEW contact person for this church registering for camp?*

Yes
No

Your name:*

Your Cell Phone*

Email*

Your Address*

Street Address City State ZIP Code

Church Employee or Church Contact?*

Church Employee
Church Contact

Your Title:

Your gender:*

Male
Female

Date of Birth (to avoid duplicate names in online system)*

How many spots are you reserving for camp?

You must have 1 adult male per 8 male students and 1 adult female per 8 female students. Your primary adult leader for each gender must be, at minimum, 21 years of age.

What method will you pay for camp deposit?*

Mail a check to Tall Timbers
Pay by credit card with this form

Number of male chaperones*

Price: $50.00

All fields are required. Type '0' if there are none.

Number of male students*

Price: $50.00

Number of female chaperones*

Price: $50.00

Number of female students*

Price: $50.00

Total people in your group:

Total Deposit Amount ($50 per person due)

$0.00

Number of male chaperones*

Number of male students*

Number of female chaperones*

Number of female students*

Total people in your group:

Total deposit amount by check ($50 per person due)

LODGING

Basic Rate is for cabin stay and no linens provided. Lee Lodge hotel rooms are available on a first come, first-served basis for an additional $30 per person. Each Lee Lodge room holds two full size beds with a bathroom/shower and with towels and bed linens provided.

Choose Lodging*

Cabins
Lee Lodge

Choose from the following:*

I would like my entire group (both genders) in Lee Lodge.
I would like all of the females in my group in Lee Lodge.
I would like all of the males in my group in Lee Lodge.
Other scenario (explain below)

Type any special needs in regards to lodging below; i.e. no stairs, handicap, etc.

Please choose one security question of your choice for us to set up your online registration and provide the answer below:*

What is the name of the city in which you were born?
What is the name of the elementary school you attended?
What is your favorite color?
What is your mother's maiden name?
What is your pet's name?

Answer:*

Payment for Deposit

Deposits must accompany this hold form to secure spots at camp. If your church prefers to send a check, and you chose "mail a check to Tall Timbers," we must receive your check no later than 2 weeks from the submission of this hold form, or your spaces will be released. DEPOSITS ARE NON-REFUNDABLE.

Credit Card Payment for Deposit*

Card Details

Cardholder Name