| CAMP DIRECTOR Bill Concoff bill@campakiba.org 818-203-9509
CAMP AKIBA 5249 S. Sepulveda BL. Culver City, CA 90230
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PROGRAM DIRECTOR Rick Degelsmith rick@campakiba.org
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1. NAME _______________________________________________ AGE _____________ GRADE IN SEPT. ______ AGE _____________ GRADE IN SEPT. ______ AGE _____________ GRADE IN SEPT. ______ ADDRESS ____________________________________________ CITY _____________ ZIP ______ PHONE ________________
TEMPLE MEMBER OF ________________ AMOUNT ENCLOSED $ ______________ ($400 per camper minimum deposit)
PARENT SIGNATURE ____________________________________ DATE ___________________
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2/27/07