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A Residential Camp for Children and Teenagers with Epilepsy

>
Ruling
Over
Epilepsy
Helps
Realize Dreams

RESERVATION FORM

Instructions

1. Fill in the information on the form below.
2. Press the SUBMIT button.
3. On the next screen, you will be able make your reservation payment through PayPal..
4. You will receive a confirmation email within 24 hours of your reservation.

Guardian's Name
Address
City
State
Zip Code
Phone Number
Email Address
Camper's Name
Best Time to Call
Birth Date
Day Time Phone Number
How Did You Hear About Camp?