Peace Camp Registration Form

Parent must fill out and mail or email back to Heartland Farm by May 15, 2020

Address: 1049 CR 390, Pawnee Rock, KS 67567

Peace Camp 2020 Registration

Parent/Guardian Name(s) *

first and last name

Address *

Address

City

State/Province

Zip/Postal

Country

Phone *

Email *

Number of Campers Registering *

First and Last Name of Camper 1 *

first and last name

Age of Camper 1 on 6/6/22 *

First and Last Name of Camper 2 *

first and last name

Age of Camper 2 on 6/6/22 *

First and Last Name of Camper 3 *

first and last name

Age of Camper 3 on 6/6/22 *

My campers will ride the van to camp.

Yes

If yes, campers will ride the van from:

Great Bend

Larned

“Oneness with Earth Heals.”