Project Venture International Camp Registration

Project Venture 2011 International Camp

To register, please fill out all fields and either submit on-line; print and fax (505-554-2291); or print and mail to: NIYLP, 924 Park Ave. Suite A, Albuquerque NM 87102.

* = Required Section

* Name and Email

First name:
Last name:
Email address:
Re-enter email address:

* Organization Contact Information

Organization name:
Street address:
Street address line two:
City:
State:
Zip:
Phone: (xxx-xxx-xxxx)
Fax: (xxx-xxx-xxxx)

* Personal Contact Information

Street address:
Street address line two:
City:
State:
Zip:
Phone: (xxx-xxx-xxxx)
Cellphone: (xxx-xxx-xxxx)

* At which address do you want to receive materials related to the camp?

Home
Work

I will chaperone the following middle-school aged youth from my program:

	Last Name	First Name	Date of Birth
1.
2.
3.
4.

Additional training option for Project Venture Camp chaperones:

Project Venture Implementation Training (Additional Fee of $100)

If you are flying into Albuquerque, please select:

I will rent a high clearance vehicle.
I will rent a car to get to Sky City and require a shuttle to camp.
I desire shuttle service if available.

Arrival time:
Arrival date:
Departure time:
Departure date:

* Payment:

Fee schedule:
Adult Chaperone - $ 500
Project Venture Implementation Training (additional fee for adult chaperones) - $100
Project Venture Camp Implementation Training only - $600
Youth - $ 400 per camper

Total amount due: $
Project Venture replication sites may be eligible for a limited amount of financial assistance. Contact bwonson@niylp.org for more info.

* I will pay by:

Purchase Order - Enter PO Number:
Check by mail (send to NIYLP; PO Box 2140; Gallup NM 87301).
On-line Credit Card Payments accepted through PayPal.
(Go to http://niylp.org/support.htm after submitting this registraion form)
Other: Please explain in the additional information area below:

Additional information:

Click here to check input before printing.

Click here to submit registration via email.