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 12 through July 25, 2009   Full Session - $800.00

_____  July 12 - July 18, 2009 Half Session - $450.00 - If Available

_____  July 19 - July 25, 2009 Half Session - $450.00 - 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.