Black Range Camp
Reservation Form

Print this and mail to:
Black Range Camp
P. O. Box 152
Winston, NM  87943

Name     ____________________________________________________

Boy     _____    Girl    _____     Age    _____

Address ___________________________________________________

City    _____________________     State_________   ZIP_________

Phone   ____________________________________________________

_____ July 8 through July 21, 2012   Full Session - $900.00

_____  July 8 - July 14, 2012 Half Session - $500.00 - If Available

_____  July 15 - July 21, 2012 Half Session - $500.00 - If Available

Referred* by________________________________________________

"Referred by" is the person who told you about the Black Range Camp and will return this year.  He or she will receive $50.00 for referral fee.