Breakaway Camp 4 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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)*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How 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 Quantity* Price: $50.00 Quantity All fields are required. Type'0' if there are none.Number of male students Quantity* Price: $50.00 Quantity All fields are required. Type'0' if there are none.Number of female chaperones Quantity* Price: $50.00 Quantity All fields are required. Type'0' if there are none.Number of female students Quantity* Price: $50.00 Quantity All fields are required. Type'0' if there are none.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)Rates and Lodging:Our basic rate is for a cabin stay with 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 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 DepositDeposits 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 Δ
