| SSAMC REGISTRATION FORM |
| Date: _________________ |
| Name (Last): _____________________________ (First): ___________________________ |
| Address (Street): ___________________________________________________________ |
| Address (City): __________________________________(State):______(ZIP):__________ |
| Telephone: __________________________ E-mail: _______________________________ |
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| No. of ADULT Individual Registrations @ $ 175 each:__________Subtotal: $_________ |
| No. of COUPLE Registrations @ $ 295 each:_________ Subtotal: $_________ |
| No. of AGE 13-18 Registrations @ $ 110 each:_________Subtotal: $_________ |
| No. of AGE 7-12 Registrations @ $ 75 each:_________Subtotal: $_________ |
| No. of AGE 0-6 Registrations (free):_________Subtotal: $_________ |
| No. of ADULTS attending, not taking classes @ $ 20 each:_________Subtotal: $_________ |
| No. of CHILDREN attending, not taking classes (free):_________Subtotal: $_________ |
| No. of BUNKS FOR REGISTERED STUDENTS @15 each:_________Subtotal: $_________ |
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| TOTAL PAYMENT IN FULL of $ _________________ is enclosed with this registration. |
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Payment accepted by check or money order. Producer of the SSAMC is Charles C. Groth. MAKE CHECKS OR MONEY ORDERS PAYABLE TO CHARLES C. GROTH ONLY. Do not write checks/money orders to the Sunshine State Acoustic Music Camp. Send registration form and payment to: DOUG PURCELL, 7200 SUNSHINE SKYWAY LANE # 3C, ST. PETERSBURG, FLORIDA 33711. IMPORTANT: WRITE "CAMP" ON THE FRONT OF THE ENVELOPE BEFORE MAILING. Thank you! See You At The Camp!! |
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