Parent Name : First Last

    Home Address
    Street AddressAddress Line 2City

    State / Province / RegionPostal / Zip Code

    Country

    Email

    Cell Phone Number--

    Home Phone Number--

    Work Phone Number--


    Season of Interest?

    2013201420152016
    (Check all that apply.)


    Camper 1
    Name : First Last
    Current Age:
    Current Grade:


    Camper 2
    Name : First Last
    Current Age:
    Current Grade:


    Camper 3
    Name : First Last
    Current Age:
    Current Grade:


    How did you hear about us?
    Web searchA friend who goes to LakotaA friend who heard about LakotaCamp FairReferral AgentOther

    If other, please tell us how you heard about us.

    What session length are you considering?

    Full 7 weeksFirst 4 week sessionLast 3 week session


    How would you like us to contact you?

    PhoneEmail


    Where would you like us to contact you?

    HomeWork


    Questions/Comments

    Summer Address...

    56 Park Road - Wurtsboro, NY 12790

    Ph: 1-845-888-5611

    Fax: 1-845-402-7440

    Email: Info@CampLakota.com

     

    Winter Address...

    26 Gedney Way Chappaqua, NY 10514

    Ph: 1-866-7-LAKOTA (1-866-752-5682)

    Fax: 1-845-402-7440

    Email: Info@CampLakota.com


    Florida Winter Office:

    Ph: 1-561-445-8502